9W^ 



5«i'v 



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VAV.V 






LIBRARY OF CONGRESS. 

Slielf...Vj 



UNITED STATES OF AMERICA. 



PRACTICAL TREATISE 



ON THE 



DISEASES OF CHILDREN. 



ALFRED VOGEL, M. D., 

PEOPESoOR OF CLINICAL MEDICINE IN THE TTNIVEKSITT OP DOKPAT, EIJSSIA. 



TRANSLATED AND EDITED BY 

H. RAPHAEL, M.D., 

FOR.MERLT HOUSE SUEGEON TO BELLETXTE HOSPITAL, PHYSICIAN TO THE EASTEEN DISPENSAET FOE 

THE DISEASES OF CHTLDEEN, ATTENDING PHYSICIAN BELLEVUE HOSPITAL OtTT-PATIENT 

DEPARTMENT, DISEASES OF GENITO-URINARY ORGANS AND SYPHILIS, ETC. 



TJJIED A3IEEICAN FROM THE EIGHTH GERMAN EDITION, 
REVISED AND ENLARGED. 



f 






ILLUSTRATED BY SIX LITHOGRAPHIC PLATES. 



NEW YORK: 
D. APPLETON AND COMPANY, 

1, 3, AND 5 BOND STREET. 
1885. 






COPTEIGHT, 1869, 1885, 
By D. APPLETON AND COMPANY. 



PREFACE TO THE EIGHTH GERMAN EDITION. 



The favor with which my " Treatise on the Diseases of 
Children " has been received by my associates and students, its 
translation into all the principal languages of the civilized 
world, and the rapid consumption of the last edition, afford 
me sufficient assurance that it has been of some use to the pro- 
fession. 

In this edition the chapters on Artificial Nutrition, on the 
Difficulties of Dentition, and on jSTervous Diseases, have had 
considerable additions made to them. Especially has the ques- 
tion which is so important in the Psediatrics, concerning the 
presumed danger of transmitting tuberculosis from the cow to 
the child by means of the milk, been briefly but fairly dis- 
cussed. In addition, new remedies, such as sahcylic acid, apo- 
morphine, eucalyptus, and their subcutaneous uses, have been 
mentioned in connection with various diseases, and their advan- 
tages and disadvantages in children's practice have been pointed 
out. 

In conclusion, I would remind the reader of the words of 
the Satyrs : 

" Sunt bona, sunt qusedam mediocrise, sunt mala plura 
Qua3 legis hie, aliter non fit avite liber." 

ALFKED VOGEL. 
DoKPAT, January^ 1881^. 



PREFACE TO THE THIRD AMERICAN EDITION. 



The acknowledged importance of Yogel's " Lelirbucli der 
Kinderkrankbeiten," the exhaustion some time since of the 
second American edition of that work, and the new subjects 
introduced into the author's revised edition, are my reasons for 
presenting to the medical j)rofes6ion of this country a third 
edition in the English language, corrected and enlarged, and to 
which I have thought it expedient to add an article on Cerebro- 
spinal Meningitis, and the various notes marked in brackets. 

The new matter embodied in this new issue comprises all 
that is contained in the authors eighth German edition, re- 
cently published ; and, although these additions are compara- 
tively limited, their practical importance will at once be con- 
ceded by every student and practitioner. The arrangement of 
the Infectious Diseases in this issue will also be found to be 
more scientilically correct. 

H. RAPHAEL. 

New York, i/"a//, 1885. 



PREFACE TO THE FIRST AMERICAN EDITION. 



Toward the close of 1868 1 informed Professor Yogel that 
I had taken the liberty of translating his excellent treatise on 
the Diseases of Children ; he kindly and promptly replied, giv- 
ing his consent to the publication of the translation, informing 
me at the same time that the work was also in the course of 
translation into the Polish language, and that the fourth edition 
of the original was just then in press and would be issued early 
in the year 1869. He very considerately forwarded to me the 
additional articles of the last edition, and recommended their 
insertion in my translation, in order to make it correspond in all 
respects to the fourth German edition.- 

The subjects alluded to are : (1), on the method of preparing 
the so-called Liebig's soup ; (2), on sclerosis of the sterno-cleido 
mastoideus muscle ; and (3), on rubeola — this last the author, in 
common with many eminent European physicians, regards as a 
Beparate and distinct disease from morbilli. 

The facts of Yogel's " Kinderkrankheiten " having been 
translated into three other languages, and of its having attained 
to the fourth edition in less than eight years, together with the 
flattering commendations of the critics in various countries, and 
his belief in its utility and merit and its adaptation to the wants 
both of the practitioner and the student, must account for the 
translator having undertaken to render an English version of it. 



vi rREFACE TO THE FIRST AMERICAN EDITION. 

The work will be found to be well up to the present state 
of pathological knowledge ; complete without unnecessary pro- 
lixity ; its symptomatology accurate, evidently the result of care- 
ful observation of a competent and experienced clinical prac- 
titioner. The diao-nosis and differential relations of diseases to 
each other are accurately described, and the therapeutics ju- 
dicious and discriminating. All polypharmacy is discarded, 
and only the remedies which appeared useful to the author com- 
mended. 

"Without in any way detracting from the merit of the n'l- 
merous works upon the Diseases of Children which exist in our 
own and other languages, he ventures to assert his belief that 
the work of Yogel contains much that must gain for it the 
merited praise of all impartial judges, and prove it to be an 
invaluable text-book for the student and practitioner, and a safe 
and useful guide in the difficult but all-important department 
of Psediatrica. 

In the efforts at converting the original into our own ver- 
nacular tongue, all thoughts of elegancy as to style have been 
renounced ; the only object aimed at was to present it in as clear 
and intelligible language as possible, to make the translation a 
worthy counterpart of the original, and to express the true ideas 
and intentions of the illustrious author ; how w^ell I have suc- 
ceeded, time and the favor which it receives at the hands of the 
profession of this country will tell. 

H. KAPHiVEL. 

New York:, August, 1869, 



PREFACE TO THE THIRD GERMAN EDITION. 



Aftee three years I experience the great pleasure of placing 
my treatise on the Diseases of Children, for the third time, be- 
fore my colleagues and those younger in the profession, and am 
quite convinced that my labor has not been wholly unappre- 
ciated. As a mark of still further recognition, it may be stated 
that two years ago a Russian translation, under the direction of 
M. Zelensky, followed the one in Dutch. As regards the im- 
provements and additions, they are not considerable. But the 
chapter on Diphtheria had to be remodeled, because the descrip- 
tion in the first and second editions answered more to the spo- 
radic form resulting from scarlatina, etc., while the epidemic 
type with which I only became acquainted in the last few years, 
through personal observation, had not been exhaustively esti- 
mated. And now with pleasure I once more present this work 
to the young practitioner, trusting that it will aid him on the 
occasions of diagnostic doubt and therapeutic embarrassments, 
to which every beginner is liable, and elevate the vacillating 

confidence in his medical skill. 

ALFEED VOGEL. 
DoEPAT, October^ 186G. 



PREFACE TO THE SECOND AMERICAN EDITION. 



I TAKE great pleasure in presenting to the medical profession 
a second edition of the translation of Yogel's " Treatise on 
the Diseases of Children." The fact that the first edition has 
been exliausted in less than a year from its publication, and the 
almost unanimous encomiums which the book has received from 
the medical press, both in this country and in Europe, are a suf- 
ficient guarantee of the excellence of the work. "No alterations 
have been made in the text, but the opportunity has been taken 
to supply a few notes on the pathology and treatment of certain 
special diseases. These notes are abstracts of important papers 
which have appeared since the publication of the fourth edition 
in the original language. 

H. Eaphael. 

December, 1870. 



OOI^TEISTTS. 



PAGE 

Preface v 

1.—INTR on UCTOR Y REMARKS. 
CHAPTER I. 

ANATOilO-PATHOLOGICAL OBSERVATIONS UPON 
THE INFANTILE ORGANISM. 

A. — Eespiration and Circulation. 

Ductus Venosus Arantii 1 

Ductus Arteriosus Botalli 2 

Foramen Ovale 2 

Arteriae Umbilicales 2 

Thymus Gland 3 

B. — Secretions. 

Meconium 4 

Uric-Acid Infarction 5 

Cutaneous Secretion, Seborrhoea Ca- 

pillitii 6 

C. — Groicth. 

General Growth 7 

Fontanels 8 

Erujition of the Teeth 11 

CHAPTER II. 

GENERAL RULES FOR THE EXAMINATION OF 
CHILDREN. 

Expression of Countenance 15 

Attitude 16 

Pulse 17 

Thermometric Measurements 18 

Thoracic Cavity 19 

Abdominal Cavity 21 

Cry and Cough 28 

CHAPTER III. 

NURSING AND CARE OF CHILDREN. 

Selection of a Wet-nurse 30 

Analysis of the Milk 34 



PAGE 

Weaning 42 

Artificial Nutrition 44 

Bathing, Drcssincr, Residence 53 



II.— SPECIAL SUBJECTS. 
CHAPTER I. 

DISEASES ORIGINATING DIRECTLY AS A RE- 
SULT OF THE DELIVERY. 

A. Asphyxia Neonatorum 54 

B. Atelectasis Pulmonum 57 

C. Cephalfematoma 59 

D. Diseases of the Navel 61 

(1.) Inflammation of the Umbilical 

Vessels 62 

(2.) Blenorrhoea and Ulceration of 

Navel 63 

(3.) Gangrene of the Navel 64 

(4.) Ulceration of the Umbilical 

Stump 64 

(5.) Ilfemorrhage of the Navel 64 

(6.) Hernias of the Navel 65 

E. Trismus and Tetanus of the New- 

born 67 

F. Scleroma 70 

G. Melfena Neonatorum 73 

H. Icterus Neonatorum 74 

I. Conjunctivitis Blenorrhoica Neona- 
torum 76 

J. Mastitis Neonatorum 83 

CHAPTER II. 

DISEASES OF THE APPARATUS OF DIGESTION. 

A. — Mouth. 

(1.) Harelip and Cleft Palate 84 

(2.) Constriction of the Mouth 87 

(3.) Imperfect Development of the 

Tongue 88 

(4.) ITvpcrtrophy and Prolapse of the 

tongue 88 

(5.) Abnormal Adhesions of the 

Tongue 89 



CONTENTS. 



PAGE 

(6.) Ranula yO 

(7.) Catarrlial Inflammation of the 
Mucous Membrane of the 

Mouth 91 

(8.) Putrid Sore Mouth 96 

(9.) Scorbutic Inflammation of the 
Mucous Membiane of the 

Mouth 96 

(10.) Noma 97 

(11.) Thrush 99 

APPENDIX. 

(a.) Si'^nification of a Coated 

Tongue in Children 105 

{b.) Diflicuit Dentition 106 

B. — Parotis. 

(1.) Hypertrophy of the Parotid 

Gland 112 

C. — Pharynx and (Esophagus. 

(1.) Angina Tonsillaris 113 

(2.) Ilypertrophia Tonsillarum 115 

(3.) Retropharyngeal Abscesses. .. . 116 
(4 ) Inflammation of the G:;sopha- 

gus 118 

(5.) Congenital Fistula of the Neck. 119 
(6.) Sclerosis of the Stcrno-cleido- 

raastoideus Muscle 120 

D. — Stomach and Intestinal Canal. 

(1.) Tlie ifost Important Symptoms 
of Diseases of the Stomach 

and Intestines 1 20 

(rt.) Dyspepsia 121 

(h.) Bulimia 123 

(c.) Vomiting 124 

('/.) Flatulence and Colic 127 

(e.) Diarrhn-a .... 131 

(/.) Constipation 134 

(2.) Catarrh of the Gastric Mucous 

Membrane 136 

(3.) Toxic Inflammation of the 

Stomach 138 

(4.) The Perforating Ulcer of the 

Stomach 140 

(5.) Ilfemorrhagic Erosions of the 

Gastric -Mucous Membrane... 140 

Softening of tlie Stomach 141 

(6.) Catarrhal Inflammation of the 

Intestines 146 

(7.) Enteritis Folliculosa and Tabes 

Mesenterica 153 

(8.) Dysentery— The Flux 157 

(9.) Intussusceptions 160 

(loi Inguinal Hernia 163 

(11.) Fissura Ani 165 

(12.) Polypi of the Rectum 166 

(13.) Prolapsus Ani , 167 



PAGE 

(14.) Malformations of the Anus and 

Rectum 169 

(15.) Entozoae, Enthelminthes, Hel- 
minthiasis, Worm Disease. ... 172 

E. — Liver. 

(1.) Syphilitic Inflammation of the 

Liver 182 

(2.) The Fatty Liver 183 

(3.) Congenital Anomalies 186 

F. — Spleen. 
Idiopathic Hypertrophy of the Spleen. 187 

G. — Peritonceum. 

(1 ) Peritonitis 188 

(2.) Ascites 190 

(3.) Diseases of the Mesenteric 

Glands 192 

CHAPTER IH. 

DISEASES OF THE ORGANS OF CIRCULATION. 

A. — Heart and Vascular TrunTcs. 

(1.) Congenital Anomalies 1S2 

(2.) Endocarditis, Pericarditis, and 

Rheumatismus Acutus 199 

(3.) Hydropericardium 208 

B. — Arteries and Veins. 

(1.) Erectile Tumors 210 

(2.) Thrombi of the Sinuses of the 

Dura Mater 210 

CHAPTER IV. 

DISEASES OF THE ORGANS OF RESPIRATION. 

A. — Nasal Cavities. 

(1.) Epistaxis, Bleeding of the Nose. 213 

(2.) Coryza, Rhinitis, Catarrh 215 

(3.) Adventitious Growths in the 

Nose 217 

(4.) Foreign Bodies in the Nose.. . . 218 

B. — Larynx and Trachea. 

(1.) Pseudo-croup 219 

(2.) Neuroses of the Larynx 222 

(rt.) Spasmus Glottidis 222 

{b.) Paralysis Glottidis 230 

C. — Thyroid Gland. 
Struma 231 

D, — Thymus Gland. 
Asthma thymicum 233 



CONTENTS. 



XI 



E. — Lungs. page 

(1.) Bronchial Catarrh 2S4 

(2. ) Pneumonia 241 

(3.) Acquired Atelectasis of the 

Lungs 250 

(4.) Pulmonary Emphysema 253 

(5.) Qildema Pulmonum 255 

(6.) Haemorrhage from the Lungs . . 257 
(7.) Hsemoptoic Pulmonary Infarc- 
tion 258 

(8.) Gangrene of the Lungs 25 y 

(9.) Periodic Night-cough 261 

F, — Pleura. 

(1.) Pleurisy 262 

(2.) Hydrothorax 269 

CHAPTER V. 

DISEASES OF THE NERTOCS SYSTEM. 

A. — Brain. 

(1.) Hydrocephalus Acutus Internus . 271 
(2.) Meningitis Simplex, Purulenta, 

and Encephalitis 291 

(3.) Sunstroke 294 

(4.) Hydrocephaloid and Irritatio 

Cerebri 295 

(5.) Hydrocephalus Chronicus 297 

(6.) Encephalocele 302 

(7.) Sclerosis of the Brain 304 

(8.) Neoplasms of the Brain 304 

(a.) Tubercle 305 

{h.) Carcinoma 306 

(c.) Entozoaj 306 

(9.) Congenital Malformations 307 

B. — Diseases of the Spinal Cord and 
Memhranes. 

(1.) Spinal Meningitis and Myelitis. . 308 

(2.) Spina Bifida, Hydro rrhachia. ... 312 

C. — Disturlances of the Nervous 
Functions. 

(1.) Eclampsia Infantum — Convul- 
sions 315 

(2.) Paralysis 323 

(3.) Chorea Minor 329 

(4.) Chorea Major 338 

(5.) Epilepsy 341 

APPENDI.^. 

A. Suctus Voluptabilis 351 

B. Diseases of the Mind 353 

C. — Iliglier Organs of Sense. 

I.—Sif/ht 3^5 

(1.) Epicanthus 366 



PAGE 

(2.) Cyclopia 356 

(3.) Malformations of the Eyeball. . . 356 

II. — Hearing 358 

(1.) Malformation of the Organ of 

Hearing 358 

(a.) Absence of the Auricxilse 358 

(6.) Occlusion of the Meatus Audi- 

torius 359 

(2.) Simple Inflammation of the 

Meatus Auditorius 360 

(3.) Abscesses in the Meatus Audi- 
torius 363 

(4.) Inflammation of the Middle Ear. 364 

(5.) Otitis Interna, the Real 366 

(6.) Foreign Bodies in the Ear. .... 370 

CHAPTER VI. 

DISEASES OF THE BLADDER AND GENITAL 
ORGANS. 

A. — Kidneys. 

(L) Malformation of the Kidnej's. . . 372 
(2.) Uric-Acid Infarction of the New- 
born 372 

(3.) Morbus Brightii. 374 

(4.) Renal Calculi, Renal Tubercles, 

Renal Cysts 379 

B. — Bladder. 

(1.) Malformation 380 

{«.) Total Absence of Bladder 380 

{b.) Fissure of Bladder 381 

(c.) Cloacae 383 

(2.) Cystitis 383 

(3.) Incontinentia Urinae 385 

(4.) Ischuria 388 

(5.) Vesical Calculi 389 

0. — Male Genitals. 

I. — Penis 392 

(1.) Malformations 392 

(a) Congenital Phimosis 392 

{b.) Congenital Paraphimosis 393 

(c.) Congenital Closure of Meatus. 393 

id.) Hypospadia aud Epispadia . . . 393 

(2.) Balanitis 394 

(3.) Acquired Paraphimosis 395 

(4.) Onanism 396 

ll.— Tcstia 398 

(1.) Cryptorchidia 398 

(2.) Hydrocele 399 

D. — Female Genitals. 

(1.^ Malformations 402 

(2.) Catarrh of the Genital Mucous 

Membrane 404 

(3.) Vaginal Haemorrhage 406 



Xll 



CONTEXTS. 



PAGE 

CHAPTER VII. 

SECTION I. ERUPTIVE FEVEP.S. 

(1.) Scai-let Fever 408 

(2.) Measles 418 

(3.) Rubeolas (Ruthcln) 428 

(4.) Variola — Small-pox 430 

Vaccination 433 

(5.) Modified Small-pox, Varioloid 

and Varicella, Chicken-pox. . . . 439 

SECTION II. MIASIL-VTIC DISEASES. 

(1.) Diphtheria of the Mouth 446 

(2.) Diphtheritic Croup 453 

(3.) Diphtheritis and Gangrene of the 

Female Genitals 476 

(4.) Typhus Fever 477 

(5.) Corebro-spinal Meningitis 497 

(6.) Cholera 505 

(7.) Whooping-Cough 613 

(8.) Parotitis Contagiosa 526 

SECTION III. MALARIAL DISEASES. 

A. Intermittent Fever 530 



CHAPTER VIII. 

LOCAL DISEASES OF THE SKtN. 

(1.) Erythema Neonatorum.. 534 

(2.) Intertrigo (Chafing) 535 

(3.) Furunculosis 536 

(4.) Scabies (Itch) 537 

(5.) Congenital Nasvi (Mother's-Maik) 539 



PAGE 

(6.) Burns , 541 

(7.) Congelatio, Frost-bite, Chilblain . 542 

CHAPTER IX. 

GENERAL DISEASES OF THE SECRETIONS. 

DyscrasicB, Gachexioe. 

(1.) Rachitis, Rickets, English Dis- 
ease, Double Limbs 544 

A. Rachitis of the Skull 549 

B. Rachitis of the Thorax 552 

C. Rachitis of the Pelvis and of 

the Extremities 554 

(2.) Tuberculosis and Scrofulosis. . . , 559 

A. The Tuberculous Cachexia. . 660 
(1.) Tuberculosis of the Lungs and 

Bronchial Glands 565 

(2.) Carcinoma of the Lungs 572 

B. The Scrofulous Cachexia. . . . 574 

(a.) Skin 676 

(6.) Mucous Membrane and Organs 

of Sense 579 

Nose 580 

Eve 580 

Ear 585 

{c.) Lymphatic Glands and Subcu- 
taneous Cellular Tissue 585 

(fZ.) Bones 587 

(e.) Joints 602 

(3.) Hereditary Syphilis 620 

(ad L) Skin 620 

(ad 2.) Mucous Membranes 623 

(ad 3.) Subcutaneous Cellular Tis- 
sue 623 

(ad 4.) Muscles and Bones 624 

(ad 5.) Glandular Internal Organs. 624 



PAKT I. 

Il^TB OB UGTOE T REMARKS. 



t^HAPTER I. 

AlfATOMO-PHYSIOLOGICAL REMARKS UPON THE INFANTILE 

ORGANISM. 

A. Respiration akd Circulation". — The first act of the new-born 
IS to inspire. Immediately after birth the muscles of inspiration 
contract, and the air finds its way for the first time into the pulmonary 
vesicles. The increase in volume of the lungs consequent upon this 
act gives rise on the one hand to an outward enlargement of the 
thorax, but on the other to a compression of those internal organs of 
the chest in juxtaposition with the lungs, ^. e., heart, large blood-vessels, 
and thymus gland, and also to a depression of the diaphragm, whereby 
a palpable pressure is necessarily exerted upon the abdominal viscera. 
This sudden change in volume of both thoracic and abdominal viscera, 
in connection with other physiological alterations, leads doubtless to 
alterations in the circulation of the different organs, and the following 
foetal circulation, in fact, becomes established immediately or soon after 
birth. 

(1.) The Ductus Venosus Arantii (Plate I., Fig. 2). — The umbilical 
vein arising from the placenta (PI. I., Fig. 5), after its entrance 
through the umbilical ring, runs between the peritonaeum and transver- 
salis muscle to the liver, and through the fossa longitudinalis anterior 
sinistra backward to the left end of the fossa transversa. Here it 
divides into two branches, of which one, the larger, communicates 
with the portal vein, and the smaller, the ductus venosus Arantii, 
leads into the inf. vena cava (PI. I., Fig. 3). The duct. ven. Aran- 
tii, therefore, connects the vena cava ascendens with the umbilical 
vein, but this connection, as well as that with the jiortal vein, ceases 
as soon as the placenta is expelled from the uterus, and the blood in the 



2 DISEASES OF CHILDREN. 

umbilical vein has become stagnant, and tlie first inspiration taken 
place. 

(2.) The Ductus Arteriosus Botalii (PI. I., Fig. 2) is, in the foetus, 
a communicating canal between the pulmonary artery and the aorta. 
It arises at the point where the pulmonary artery divides into the two 
branches, then runs obliquely upward toward the lower border of the 
arch of the aorta, and joins the latter at a point opposite to where the 
left subclavian artery dips into it from above. It serves to arrest the 
blood in its course toward the lungs, and to conduct it from the 
right side of the heart directly into the great current again. The 
nearer the end of gestation arrives the smaller this vessel becomes, 
while the two branches of the pulmonary artery grow larger; the 
broader, however, this vessel is, so much the narrower is that portion of 
the aorta Avhich lies between it and the heart. And now the lungs, 
dilated by the inspiratory muscles, not only draw in air, but also blood 
from the vessels ; not only the air-vessels, but also the J/ooc^-conducting 
system of vessels, become distended. A stronger and faster blood- 
current passes from the pulmonary artery toward the lungs ; the arter}'' 
sends no more blood through the fcetal passage communicating with 
the aorta {the ductus JBotalii), and the latter is so quickly obliterated, 
that in a child twenty-four to thirty-six hours old it is scarcely large 
enough to admit a probe. 

(3.) The Foramen Ovale. — In the foetus the auricular septum con- 
tains an opening (for. ovale), corresponding to the fossa ovalis in the 
adult. In this opening a semilunar membranous valve (valvula fora- 
minis ovalis) is found, the upper border of which is free. In the 
foetus this valve closes the foramen very imperfectly, so that a por- 
tion of the blood passes directly from the right into the left auricle, 
and thence, without permeating the lungs, into the general circulation. 
The nearer the end of gestation arrives, therefore, the smaller this fora- 
men becomes, and the stronger and firmer the valve. After birth, the 
lungs are suddenly converted into a suction-apparatus, they therefore 
require a larger quantity of blood for their supply; the right ventricle 
also becomes distended, and thus the blood-stream is diverted from the 
foramen ovale. Although the border of the valve usually remains free 
for some months, still it is so well developed that it accurately closes 
the foramen. In children over eight to ten months of age, this border 
of the valve is generally found united with the corresponding border 
of the foramen ovale. 

(4.) The Umbilical Arteries (art. umbilicales, PI. I., Fig. 4). — Hav- 
ing spoken of the imibilical vein in connection with the closure of the 
duct. ven. Arantii, there only remains to describe the obliteration 
of the umbilical arteries. The two arteries originate from the cor- 



REMARKS UPON THE INFANTILE ORGANISM. 8 

responding arter. lijrpogastrica, are thicker than all its other branches, 
and pass upward along the bladder. They embrace the urachus and 
with it run upward between the abdominal muscles and peritonaeum 
to the umbilicus. Passing through the umbilical ring, they run spirally 
in the cord, and reach the placenta, in which they divide and subdivide. 
As soon as the connection between the uterus and placenta has ceased, 
thrombi form in the umbilical arteries, reaching almost to their origin 
from the hypogastrica. These arteries remain pervious for a short 
distance from their point of origin, and here give off several arter. 
vesicales ; in the female, in addition the arter. uterin^e. The remain- 
ing portion, between the arter. vesic. and the ring, ultimately becomes 
obliterated and converted into a fine white cord. 

Together with these 'mecha7iical alterations, still more important 
chemical processes take place from the entrance of air into the 
lungs. Through the alternate action of air and blood, and the inter- 
change of gases, which the walls of the capillaries lying against the 
pulmonary alveoli and the walls of the alveoli themselves have 
to transmit in two opposite directions, both air and blood are so 
altered, that the former becomes irrespirable, the latter arterial and 
thus qualified for nutrition. The new-born has now both arterial 
and venous blood. 

Mention must be made here of an organ that solely belongs to 
the infantile organism, the thymus gland. The thymus is distinguished 
for great variation in size, weight, consistency, and form. 

Embedded in the anterior mediastinum, it is sometimes confined to 
the space between the upper part of the pericardium and the roots of 
the large vessels, measuring in width barely half an inch, but some- 
times reaching from the thyroid gland down to the diaphragm, and 
then measuring more than two and a half inches in width. Its principal 
arteries, according to Jendrassic^ are branches derived directly from 
the large blood-vessels upon which it lies. According to the same 
author, to whom we are indebted for most of our knowledge concerning 
this enigmatical organ, the thymus is composed of two, often very 
unequal, parts, which are united by a membrane formed of several 
delicate laminee, in which most of the principal vessels terminate. 
The form of such a thymus moiety most frequently met with is an 
oblong, the upper third sometimes thin and rovmded, while the rest 
is more flattened and broader; a larger or smaller portion often 
curves upward like a horn from the loAver end over the outer border 
of the gland. When the thymus deviates from this form, each half 
has the shape of thin cord like stripes, or when of large size is divided 
into several rounded lobules, intimately united by a thin parenchyma- 
tous structure, lying near or upon each other. 



4 DISEASES OF CHILDREN. 

In all instances the anterior surface facing the sternum is convex, 
the posterior slightly concave. The outer and lower borders are thin, 
often hem-like ; the inner is blunter, provided with deep fissures, in 
which, as in a hilum, the blood-vessels dip. 

At first the thymus is solid, firm, and granular, but in time be- 
comes converted into a softer mass, in which many cavities may 
be found containing a fluid that almost always reacts acid. The soft- 
ening progresses from the central axis, where the principal veins 
terminate in an extensive deposit of connective tissue toward the 
periphery. The gland grows constantly flatter, its cavities approach 
one another more closely, so that no more of a glandular parenchyma 
can be seen, and at the time of commencing puberty it has, as a rule, 
completely disappeared. Exceptionally, however, it may be found in 
adults, and sometimes even of decided dimension and weight. In 
tuberculous children it is found infiltrated with tubercular deposit. 
Carcinoma of the anterior mediastinum, which in children occurs com- 
paratively more frequently than in adults, most probably has its start- 
ing-point in the thymus gland. The numerously-repeated statements, 
that in syphilitic children abscesses are to be found in the thymus, are, 
according to JendrasslCy based upon an erroneous supposition, for, in 
most instances, the supposed abscesses are nothing more than the 
cavities that are regularly developed in the retrograde metamorphosis 
of the gland, and are also found in children who are perfectly free 
from syphilis. 

-B. Secretions. — All the mucous membranes, which in the foetal 
state produced but a slight amount of secretion, commence after birth 
to secrete their peculiar fluids. The mouth and nasal cavities be- 
come moist and lubricated, the latter often very imperfectly, so that it 
frequently becomes necessary to remove the dried mucous crusts. The 
salivary glands, it is true, also secrete a fluid, which, however, has not, as 
yet, the same perfect chemical properties as in the adult, for it is only 
able to very slowly convert starch into sugar. The stomach likewise 
begins to secrete a fluid, which dissolves the caseine contained in the 
milk of the mother. The liver, which fills up the greater part of the 
abdominal cavity, secretes a light-brown bile, which gives to the fceces, 
after the dark-brown meconium has been evacuated, an orange-yellow 
color. 

The generally prevaiKng opinion, that the meconium is a mixture of 
bile, intestinal mucus, and intestinal epithelium, has been proven by 
Foerster''s investigations to be incorrect. It consists rather of flat 
scales, which possess all the characteristics of flat epithelium, and 
consequently could not have originated in the intestinal canal, re- 
sembling in their entity those of the vernix caseosa : and, in addition, 



REMARKS UPON THE INFANTILE ORGANISM. 5 

of fine hairs, in the same quantity as in the latter, fat-globules of vari- 
ous sizes — e'V'idently cutaneous fat (Hauttalg, smegma cutaneum) 
peculiar to the vernix caseosa — crystals of cholesterine (which may 
partly originate in the bile, or may be retrograde products of the ver- 
nix caseosa), and irregular brownish and yellowish lumps and flakes, 
which give to the meconium its dark color, and without doubt 
the coloring matter of the bile. It is therefore evident, that the 
meconium, excepting the last-mentioned substances, which origi- 
nate in the bile, consists principally of vernix caseosa^' and from 
this it may be inferred that the foetus from time to time has swal- 
lowed a tolerably large quantity of amnion containing the vernix 
caseosa in suspension, the water of which is quickly absorbed by 
the stomach, for none is ever found in it, but the hairs and 
scales pass through the whole intestinal tract as indigestible sub- 
stances. 

After birth the intestines secrete a certain amount of mucus, an 
excessiveness or deficiency of which will give rise to diarrhoea or 
constipation, the first and most frequent diseases to which the nurs- 
ling is subject. 

Quite a severe task is imposed upon the kidneys immediately 
after birth. In the first few days children drink but very little, the 
blood consequently can part with only a very small quantity of water, 
and thus it happens that the uric acid salts, the result of the great 
metamorphosis of the tissues, quickly accumulate in the urinary tu- 
bules, remain undissolved there, and from this too highly concentrated 
solution the product that has been called the uric acid infarction of 
the new-born is deposited. The uric acid concretions are yeUowish- 
red or pink-red casts of the pyramids near the papillse. Generally 
they appear for the first time on the second day after birth, and last 
from five to twelve days, but I have also found them in children more 
than four weeks old. As this condition has been said to exist in the 
still-bom, in very exceptional cases it is true, and, since a considera- 
ble number of children who die betAveen the second and fourteenth 
days do not exhibit it, no very great medico-legal value can therefore 
be placed upon it. It is frequently found as a carmine red powder in 
the diapers of the new-born, an occurrence that has also been noticed 
by some observing midwives. Microscopic examination reveals mi- 
nute columns composed of cylindrical, amorphous, urate of ammonia, 
and epithelium cells, with here and there solitary rhomboid uric acid 
crystals. On the days this powder is found in the diapers, the chil- 
dren are usually restless, cry on micturition, and have an inflamed 
meatus. Although its origin and excretion must be regarded as 

physiological, nevertheless it cannot be denied that kidney gravel, so 

2 



6 DISEASES OF CHILDREN. 

frequent in children, as Avell as the occurrence of urinary calculi ic 
childhoocl, has some connection vritli it. 

The skin, which during foetal life was continuously of the tem- 
perature of the maternal blood, with the act of delivery becomes a 
colder medium, for now it is subject to the impressions of the air, 
light, and changes of temperature, and also assumes the function 
of secretion. At birth it has a uniform red color, which, however, 
between the second and sixth day, changes to a yellowish and then 
into the ordinary rosy-red tint. The yellowish color is often errone- 
ously regarded as icteric. New-born children are covered almost all 
over the body, with the exception of the palms of the hands and soles 
of the feet, with fine, soft, often tolerably long hairs (lanugo), which 
fall out in the first Aveeks of life. So, too, the strong hairs upon the 
head with Avhich children sometimes come into the world, fall out 
in the first weeks of life, and are only sIoavI}^ replaced by a fine, gen- 
erally light-colored growth of hair. Feeble children, of slow de- 
velopment, and those devoid of solid adipose tissue, retain these 
first hairs much longer than those which develop rapidly. In the first 
weeks of life the sweat-glands perform their function but very imper- 
fectl}'" ; it is almost impossible to bring a child, under four weeks 
old, into such a state of transpiration that the perspiration will gather 
in drops. 

On the other hand, from the beginning of the second month up 
to the end of the first year, the secretion of the sebaceous glands of 
the scalp in almost all children is increased in amount, forming sebor- 
rhoea capillitii, which should be classed with the physiological 
conditions. This seborrhoea capillitii develops very gradually ; at 
first, the scalp looks as if it had been smeared with tallow or cerate ; 
upon this hard skin dust and dirt become adherent, and, with the 
lardaceous secretion of the skin, dry into grayish-white or yelloAvish, 
and, subsequently, into brown and even black scabs, which crumble 
easily between the fingers, become detached, and leave the scalp in 
a healthy, uninjured state, and not even congested. It is not attend- 
ed by any itching, moisture, or cutaneous infiltration. By a diligent 
application of olive-oil, and washing the head Avith soap and water, 
this formation of scabs may be arrested without any danger to 
health. In many places, in Munich for instance, the midwi^'es have 
accused this affection of being a noli one tangere. It is but seldom 
possible to persuade the mothers to try the just-described method 
of treatment, most of them leaving the brown scabs untouched 
till the end of the first year, when the seborrhoea ceases spontane- 
ously, and the scabs, by the constant growth of the hair, are separated 
more and more from the scalp, and finally dr}'- up and crumble 



REMARKS UPON THE INFANTILE ORGANISM. 7 

away. Afterward, no simple seborrhcea capillitii ever occurs in 
children. 

C. The general growth of Childkei^, aistd of special Parts 
OF THEIR Bodies. — The child grows most rapidly in the first weeks of 
life ; in the first year, from six to seven inches. From the fourth 
or fifth year up to the sixteenth, its growth is tolerably regular, and 
amounts yearly to two inches, more or less. From the sixteenth to 
the seventeenth year, the body increases only one and a half inches ; 
in the two succeeding years only one inch. Most persons grow only 
to the end of the twentieth year, but in some growth is only com- 
pleted at the end of the twenty-fifth year. Imperfect nutrition, and 
too hot and too cold a climate, hinder growth. Acute febrile diseases 
interfere in no way with it ; on the contrary, they accelerate it most 
decidedly, and this is especially true of the acute exanthemata. In 
an acute febrile disease of a few weeks' duration, children often 
grow a half or one inch, while in the physiological state this would take 
three or six months time. Indeed, they even appear to have grown 
more than that amount, on account of the great emaciation that 
ensues. Diseases of the bones, rachitis, and scrofulous afi"ections, 
retard the growth. When children grow too rapidly, they become 
emaciated, weak, pale, and inert. In about one and a half to two 
months the child begins to hold the head erect and to turn it voluntarily, 
especially toward the light. Not till the seventh or eighth month 
does it learn to sit, and still later in the ninth and tenth the func- 
tions of the lower extremities are developed, the child beginning to 
stand, and several weeks thereafter to walk. 

The growth of aU parts of the body does not always progress 
uniformly ; often the head grows more than the other portions, and 
the extremities more than the trunk and head ; most frequently the 
thorax, in consequence of our defective physical rearing, is much rev 
tarded in development as to its breadth. 

Sometimes it is of importance to accurately decide the dimensions 
of the bones of the skull, and the following points of measurement 
have therefore been agreed upon: (1.) The largest periphery of the 
head. For this the measurement is taken from the tuberosity of the 
occipital bone to the greatest prominence of the frontal bone. In 
marked chronic hydrocephalus the occipital bone is more horizontal, 
and the largest periphery, therefore, strikes above the tuberosity of 
the occiput. (2.) The measurement from one ear to the other. It 
runs from the dipper part of attachment of the auricula over the greater 
fontanel to a point opposite. (3.) The 'ineasurement from the oo- 
cilJut to the root of the nose, is from the occipital protuberance over 
the top of the head to the glabella. These three measures may be 



8 DISEASES OF CHILDREN. 

taken with some strips of paper, or still better, with a tape measure 
divided into half and quarter inches. The diameters must be meas- 
ured with a compass. The transverse diameter has its terminal points 
at the protuberances of the two parietal bones, the longitudina^ 
diameter at the lesser fontanel and the greatest protuberance in the 
centre of the forehead. 

A thorough knowledge of the greater fontanel and its physiologi- 
cal closure is of great importance to the physician. The fontanels 
are conditional upon the development of the skull. The angles of 
the bones of the skuU will necessarily have to be the last formed, as 
the process of ossification of the foetal skull progresses from several 
points of ossification, which, by the addition of ossific matter to 
their peripheries, grow uniformly in every direction. But since the 
cranial bones at first have a roundish contour, there will remain, 
when the several plates of bone come together, a space between them, 
which win have as many margins as bony plates. These openings, 
covered only by a membranous tissue, are called fontanels. Now, 
since the parietal bone in its developed state has four angles, a 
fontanel would have to form at each of these in the embryonic 
state, but as the upper angles of both parietal bones lock together, 
so that their fontanels coalesce, only six fontanels can be produced, 
of which the frontal and occipital are single, but the anterior 
and posterior parietal fontanels, on the contrar}', are disposed in 
pairs. 

In a child at fuU term, only the large four-cornered frontal fontanel 
exists, the square of which forms a rhombus, with unequally in- 
wardly-curved borders. It originates from the union of the two 
frontal and the two parietal bones ; the angle formed by the union of 
the frontal bones being sharper than that formed by the union of the 
two parietal. Tlie greater fontanel seldom closes completely before 
the end of the second year. Tlie enlargement of this fontanel till after 
the ninth month of life is a very remarkable occurrence, to which 
Elsaesser first called the attention of the profession. To ascertain its 
size, Elsaesser chose a method by which probably a more precise and 
at least more relatively definite determination of its square space is 
arrived at, while at the same time it supplies a briefer expression. 
He measured the distance of two parallel sides, lying opposite each 
other, from their centres outward, the distance of the two other parallel 
sides was then similarly ascertained, the two numbers resulting there- 
from were then added together, and the half of that was accepted as the 
diameter of the fontanel. This method furnishes more exact results 
than when the measurement is taken from one corner to the opposite 
one. In the latter case the result is whoUv unreliable, because the 



KEMARKS UPON THE INFANTILE ORGANISM. 9 

angles often extend tolerably far into the sutures in the form of very 
narrow fissures, whereby the boundary from which the measures are 
to be taken is ahvays subject to arbitrariness. 

The relative sizes of the anterior fontanel were in the trimesters 
as follows : 







Average Diameter of the Fon- 


Trimesters. 


No. of Children. 


tanel in French lines. 


1 to 3 months. 


10 


9 60 


4 to 6 " 


15 


11.93 


7 to 9 " 


7 


13.90 


10 to 12 " 


13 
45 


11.88 


1 to 12 months, 


11.60 


In this period the fontanel 






isaln-ays open. 






13 to 15 months. 


9 


7.77 



Of these nine children the fontanel is closed in 3, in one 5, in the 
rest 10 to 15 lines wide. 

16 to 18 months: eight children. In 4 the fontanel is closed; in 
the rest 2, 3, 9, and 10 lines wide. 

19 to 21 months : five children. In 2 closed; in the rest, 5, 12, and 
12 lines wide. 

22 to 24 months : seven children. In 5 closed ; in the rest 9 and 
15 lines wide. 

From this it follows — 

1. That the anterior fontanel, during the first year of life, is small- 
est in the new-bom, and in the course of the first trimesters. 

2. That it then increases in size up to the third trimester ; and, 

3. It does not decrease again till the fourth. 

The question which instantly strikes one here, " How is this en- 
largement of the circumference of the greater fontanel to be ex- 
plained ? " may be answered, according to Elsaesser^ in the following 
mechanical way: The greater fontanel forms a square, with its 
angles directed forward and backward, right and left. Through the 
angles two bony fissures of the skull run, a transverse (the coronal 
suture) and a longitudinal one (sagittal and frontal). Now, if we 
suppose that the surface-growth of the bones of the skull occurs in this 
wise, that on their borders new layers of bony substance are constantly 
formed, the relative bones Avill be driven asunder by the newly-formed 
epiphysis on the borders of each suture. Now, if this happens to 
the fissures terminating at the fontanels, then they will necessarily 
grow larger in every direction, if their borders do not also grow at the 
same time. The borders, however, of the fontanels do indeed grow, 
but only in the same proportion as the margins of the sutures, and this 



10 DISEASES OF CHILDREN. 

suffices to explain the mechanical enlargement of the fontanel. If we 
think but a little further, that if only one of the above-named principal 
sutures — the transverse for example — receives new additions of mat- 
ter, the other, the longitudinal, remains unaltered, supposing, still 
further, that on each border of the transverse suture material is added 
in a certain period of time, amounting to the breadth of one French 
line, then the fontanel at the expiration of this period will in this case 
have its old diameter again, although the borders have grown by one 
line within that same period of time. Thus, then, a uniform growth 
of all the borders of the bones has been presupposed, the diameter of 
the fontanel remaining unaltered, if only one suture passed through it, 
or if no addition of substance whatever took place. But the latter oc- 
curs in the longitudinal suture in the same proportion as in the transverse. 
And since, in the growth of the borders of the transverse suture by 
one line, the borders of the fontanel must also gTOW by one line if 
its diameter should remain the same, then the same results in the 
longitudinal suture, if, uniformly with the transverse suture, it grows 
by one line in breadth ; or, in other words, if the diameter of the 
fontanel is to remain unaltered during the time in which the borders 
of the transverse and longitudinal sutures grow by one line, it must 
increase by double the quantity, namely, by two lines. This, how- 
ever, does not take place, the fontanel growing in about the same 
proportion as the margins of the sutures (thus, in the jDresumed 
period of time merely by one, not by two lines), and it must, there- 
fore, constantly increase in circumference. This is also actually the 
case. To whom the preceding explanation should not be distinct 
enough, let him take the trouble to cut out from paper four times the 
two contours, PI. II., Figs. 1 and 2, and then to set them together 
with the blunt ansrles in such a manner that the fine lines a and a' 

o 

of each figure will form a square. 

Fig. 2 represents an accurate drawing of one of the bones of 
the skull which has participated in the formation of the greater fonta- 
nel, the plate of bone having increased in a given time by one line 
all around from its original size, as in Fig. 1. 

So long as the borders of the sutures continue to grow in the same 
proportion as the borders of the fontanels, the steady enlargement 
of the fontanel naturally will continue. But a period arrives when 
the borders of the sutures become ossified, forming seams, in a more 
limited sense, and the entire head at the same time enlarges at 
a slower rate. The result of this is, that the bony margins cannot 
further separate or be displaced, and that the unchecked continued 
growth of the ununited fontanel-borders has for its object the gradual 
diminution of the fontanel. Tlie period of the simultaneous forma- 



REMARKS UPON THE INFANTILE ORGANISM. H 

Hon of the sutures, and the diminution of the fontanel, in healthy 
children, occurs about the ninth month. The fontanel does not, 
however, become completely closed till after the fifteenth month. 

The enlargement of the greater fontanel in the first three trimes- 
ters is, therefore, neither pathological, nor rachitic, but a physiolog- 
ical condition. 

The purpose of the greater fontanel is considered in a one-sided 
manner, from its negative point of view only, deficiency of firm ossi- 
fied covering, while its form, position, increase of size, taken in 
connection with the whole development of the child, show an actual, 
positive purpose. 

The skull and spinal column together form a firm, unyielding 
casing around the brain and spinal cord, so that the contents of the 
skuU and the spinal canal can neither increase nor diminish in volume. 
Now in the first year of life, when the brain grows rapidly and is 
more predisposed to congestion than subsequently, an absolute fixation 
of the skull would not allow this physiological growth, consequently 
the greater fontanel exists as an elastic point, acting very much in 
the manner of a safety-valve. 

While in congestion of the brain, and hydrocephalus, it bulges 
and arches outwardly, and thus lessens the pressure of the plethoric 
vessels or hydrocephalic effusion upon the brain, in cerebral anaemia 
and atrophy of the brain it arches inwardly and forms a depression 
on the top of the skull. 

The brain grows most rapidly in the first months of life ; at birth, 
it Aveighs less than one pound ; in the second year nearly one and a 
half pounds. In the new-born, the cerebral substance is soft, almost 
homogeneous, and is not well defined into gray and white, or cortical 
and medullary substance. In the first year the dura mater is always, 
in the second quite frequently, firmly adherent to the calvarium, so that, 
in opening the skull, the dura mater has to be removed simultaneously 
with the calvarium. It therefore seems superfluous to describe this 
phenomenon as peculiar in the autopsy of every child under one year 
of age, as is the case in most reports of autopsies, in which also a 
special amount of stress is laid upon it. 

THE ERUPTION OF THE TEETH. 

The formation of the teeth, according to Hyrtl, begins as early 
as the first third of embryonic life. In the sixtli week of pregnancy, 
according to Goodsir, narrow little grooves form at the future site 
of the maxilla between the barely-recognized lips and the rudimentary 
arch of the jaw. The margins of these grooves increase to ridges, by 



12 DISEASES OF CHILDREN. 

vvliicli the fissures are converted into excavations or inlets. At the 
bottom of these inlets little roots spring* up, between which the 
curved ridges dip down and form cells for the roots. Every cell 
communicates with the mouth by an opening which, through the 
convergence of its borders, subsequently becomes closed. Thus 
the dental sac originates, and in its depth the dental papilla is 
implanted. The dental papilla serves as a nucleus for the deposit of 
the tooth-substance (cementum), the enamel being formed by the 
enamel germ, which crowns and envelops the head of the papilla, and 
into Avhich the latter grows. In this manner the dental sacs of the first 
twenty teeth are developed, their ossification following in the fifth 
month of intra-uterine life. The sacs for the i:)eT'manent teeth sprout 
on the posterior w^alls of the deciduous dental sacs, probably with 
hollow communications. By increasing growth they become cut off 
from these, but still hang to them by a thread-like attachment (gu- 
bernaculum dentis). All the sacs of the milk and permanent teeth 
are present in the maxilla of the new-born. The deciduous teeth 
in time grow upward toward the alveolar borders of the jaw, 
which is closed by cartilage. The cause of this upward growth is 
the successive development of the dental root. The cartilage of the 
gum and the upper wall of the dental sac disappear simultaneously. 
And the lateral walls of the dental sac become the periosteum of the 
dental root. Sometimes the cartilage disappears before the crown of 
the tooth has reached the upper surface ; the erupting tooth then lies 
freely exposed in a shallow depression of the gum ; often, however, it 
cannot be seen, but only felt, and is discovered by striking upon it 
with a spoon-handle — an experiment Avhich may give much pleasure 
to the parents who are impatiently waiting for the appearance of the 
first tooth. 

Attended by increased secretion and redness of the mucous mem- 
brane of the mouth, and various other symptoms to be treated of in 
the special part, the eruption of the first milk teeth begins. In the 
majority of healthy children the twenty deciduous teeth appear in 
the following five groups : 

Group I. — Between the fourth and seventh months of life the two 
lower middle incisors appear almost simultaneously, whereupon a 
pause of three to nine weeks ensues. 

Group II. — BetAveen the eighth and tenth months of hfe the four up- 
per incisors appear, following shortly upon each other. At first 
the two central, then the two lateral. The second pause amounts 
to from six to twelve weeks. 



REMARKS UPON THE INFANTILE ORGANISM. I3 

Group III. — Between the twelfth and fifteenth months of life six teeth 
appear at once, namely, the four first molares and the two lower 
lateral incisors ; generally the molares in the upper maxilla first, 
next the lower incisors, and lastly, the molares of the lower jaw. 
A pause until the eighteenth month now ensues. 

Gkotjp IV. — Between the eighteenth and twenty-fourth months of life 
the canine teeth cut through (the upper ones are called eye-teeth). 
Again a pause until the thirtieth month. 

Gkoup V. — Between the thirtieth and thirty-sixth months, the second 
four molares finally make their appearance. 

This concludes the first dentition. The child has now twenty 
milk-teeth. In the fifth or sixth year of life the first molares cut 
through, and with them the second dentition begins. The arteries of 
the deciduous teeth become obliterated and their nerves disappear, 
and as they are thus deprived of their vitahty they become loose by 
the enlargement of the alveoli and finally fall out without pre- 
viously becoming carious. As the infantile maxilla is not large 
enough to allow the permanent teeth to be developed in a single 
row, the permanent canine is therefore compelled to grow in front 
of the external incisor and first molar, and to this remarkable situation 
of the canine tooth is also frequently due its faulty position after it has 
cut through. The partition wall which separates the alveoli of the 
permanent teeth from those of the milk-teeth is after awhile ab- 
sorbed. In order that the first may follow the latter, and that they 
may not grow amiss, the constricted cord between each milk-tooth 
and the corresponding permanent tooth is again transformed into an 
open passage. The milk-teeth fall out again in about the same order 
as they appear. In the twelfth year the fourth molar appears, and 
finally between the sixteenth and twenty-fourth year the fifth molar, 
also called wisdom-toothy the crown of which does not begin to ossify 
till the tenth year. 

Although it cannot be maintained that all healthy children cut 
their teeth in the above-described order and time, yet this much is 
certain, that those children who follow this order suiFer the least from 
the difficulties and sequelee of dentition. Under the irregularities 
of physiological dentition the following observations in particular may 
be made. (1.) Irregularity in time : Children sometimes come into 
the world with teeth, as Louis XIV. and Mirabeau, without subse- 
quently having a quicker general development. (3.) Irregularity in 
succession : Occasionally the upper incisors appear before the lower^ 
and in such cases the lateral generally before the central ; very rarely 
do the canine appear before the molares. 



14 DISEASES OF CHILDREN 

CHAPTER II. 

GENERAL RIjLES FOR THE EXAMINATION OF CHILDREN. 

Very small children, only a few weeks old, are very indifferent 
to a professional examination ; they sleep much, and feel so com- 
foiiable when relieved of the firm bandages * for a little while, that 
they are rarely restless and unquiet. But Avhen they once begin 
to recognize and distinguish surrounding objects, as is often the case 
A^dth children three months old, every strange face frightens them, 
therefore also that of the physician who is called in to attend them. 
In some children this timidity lasts only till the eighteenth or twenty- 
fourth month ; sometimes it decreases, sometimes again it increases, 
in others it persists till the fourth or sixth year. Much depends, how- 
ever, upon the circumstances under which the child grows up ; it will 
be the more timid, the fewer persons it has an opportunity to see ; 
children that grow up in the city are, therefore, less timid than those 
reared in the country. 

There are three circumstances which act as obstacles to the child's 
physician : the absence of speech, the marked agitation which the ex- 
aiTiination always induces, and, lastly, the crying which often ac- 
companies this agitation. The first obstacle, of course, cannot be 
removed ; it may, however, in a measure be replaced by a well-directed, 
comprehensive interrogation of those in charge of the child ; the last 
two, on the contrary, must be avoided. 

When a child has been Avashed, and nursed, or fed, it generally 
falls asleep ; and, as these necessities in respectable families are at- 
tended to at about the same time every day, it is therefore very easy 
to observe and examine the child while asleep, and for this purpose 
it should be dressed in such light garments as will not necessitate its 
disturbance in removing them. Its sleeping is favorable for that 
examination which can only be fully appreciated Avhen carried out 
with the utmost quietness — that part of the examination which can 
be made regardless of the agitation and crying may be deferred till 
the child is awake. From this it follows that the examination of sick 
children must be undertaken at two separate periods of time, namely, 
during its rest and duiing its agitation. The expression of the coun- 
tenance, the attitude and involuntary motions of the body and ex- 

* [In Germany, and most of the countries of Europe, the entire body of the infant 
is bandaged with a long, broad cloth.] 



RULES FOR THE EXAMINATION OF CHILDREN. 15 

tremities, the pulse, the kind and number of the respirations, and the 
results of auscultation, can onlj be properly noted during rest. The 
skin, its color, temperature, and morbid alterations ; the mouth, the 
abdomen, genitals, anus, the extremities, the manner of nursing, and, 
above all, the cry, may be examined during the agitation. 

The expression of the countenance betrays the sensations of even 
the youngest infants tolerably distinctly, and Aiay greatly aid the 
experienced observer in the recognition of diseases and the formation 
of a prognosis. Eiisehe de Scdle very correctly observes that the 
healthy nursling has a totally exjDressionless phj^siognomy, in which 
every one, a mother jjerhaps excepted, must agree with him. The 
fact is all the more important, that sick children have a certain ex- 
pression of countenance, in great part due to the disappearance of the 
adipose tissue from the subcutaneous tissues ; in part, however, 
this is due to a pecuKar contraction of the otherwisa relaxed facial 
muscles. 

The expression of the countenance of a previously healthy, robust 
child becomes so rapidly changed in every profuse diarrhoea, and espe- 
cially in Asiatic cholera, that it is often barely possible to recognize it 
again in twenty-four hours. The eyeballs sink back into the orbita, 
so that the lids are scarcely able to cover the bulbs, and a fold (corre- 
sponding to the lower border of the orbit) forms in the lower eyelid ; 
the nose becomes pointed, and the previously plump, ruddy lips be- 
come sharp and thin. 

In chronic atrophy, also, the last traces of adipose tissue disap- 
pear from the face ; the integument everywhere becomes loose and cor- 
rugated, and, in addition, various contractions of the muscles take place, 
as a result of cerebral irritation, especially that of the frontal, next of 
the corrugator supercilii, and the levator alse nasi et labii superioris 
muscles, by which the face acquires a senile appearance, and, on ac- 
count of which, the French Psediatricars, in a very ungallant manner, 
call it a Voltairian face. 

Jadelot has described three expressions of the countenance, which 
he claims indicate the existence of internal diseases. The first exjDres- 
sion begins at the internal angle of the eye, and becomes lost upon 
the zygomatic process. He calls it " le trait oculo-zygomatique." 
The second starts from the upper part of the wing of the nose and sur- 
rounds in a semicircle the external border of the orbicularis oris. This 
divides into two parts, into the nasal-expression (le trait nasal), and 
into that of the cheek (le trait genal). The third expression begins at 
the angle of the mouth, and becomes lost toward the chin. The first, 
it is claimed, denotes afiections of the brain; the second, affections of the 



16 DISEASES OF CHILDEEN. 

abdominal ; and tlie third, those of the thoracic organs. It is scarcely 
necessary for us to suggest to the reflecting physician that this is mere 
fantasy. Alas ! it will not be made so easy for the physician to recog- 
nize and diagnose a disease by merely inspecting the face. But there 
is one sin£:le siffu characteristic of a certain disease found in the face, 
namely, the rising of the alfe nasi with every inspiration, by whicli 
we are able to diagnosticate, with the greatest certainty, an inflam- 
matory affection of the lungs. 

As regards the attitude and movements of the child, the new-bom 
is always apt to assume that bodily position which it occupied within 
the uterus. The back is bent a little outwardly, the head flexed upon 
the chest, and the limbs are bent upon the body. When a child 
lies quietly, sleeps soundly and uninterruptedly, and is tolerably 
active when awake, then it may be satisfactorily concluded that it is 
in excellent health. There is a decided contrast between this state 
and the condition of powerlessness and stupor. In the former the 
mobility of the child is abolished, it lies then apathetic ; in the latter, 
on the contrary, the eyes are staring, and follow no more the eyes of 
the mother, or of the nurse ; as is the case even with very small, 
healthy nurslings, of but four weeks old, the eyelids cover only half 
of the cornea, and do not become comjDletely closed even during 
sleep. 

If children throw themselves about unceasingly, and find no rest 
in any position; when they have a heightened temperature of the 
skin, with an accelerated pulse, and then become tranquil without any 
diminution of the fever having taken place, this remission is only the 
result of increasing weakness, and may be regarded as an unfavorable 
sign. In exudative affections of the brain, children often flex the head 
backward ; in cerebral atrophy, as a result of general atrophy, they 
will constantly rub the occiput on the pillow, or bore the head into it, 
and with their little hands pull their hairs and ears. Healthy children, 
when tired, fall asleep in any posture and quietly continue to do so ; 
but in pneumonia, in most instances, they choose the dorsal decubitus, 
or lie on the affected side, and will immediately turn over if they 
happen to be placed upon the unaffected side. Children with scrofulous 
inflammations of the eyelids, and sometimes those with cephalic pains, 
lie upon the face. 

When infants during nursing, or shortly after that, are laid upon 
the left side, they generally become restless and begin to vomit ; this 
is apparently owing to the enormous size and weight of the liver, which 
in this position presses upon the stomach. For that reason also do 
nurslings suck with more ease at the left breast, for, being oftener 
put to this one, more milk is usually found in it than in the right. This 



RULES FOE THE EXAMINATION OF CHILDREN. 1^ 

argument is quite probable, from the fact that niirsliugs who obsti- 
nately refuse to suck at the right breast will very often take it with- 
out any objection as soon as their lower extreixdties have been put 
under the mother's right arm and they are allowed to nurse while 
lying upon the right side. 

Children frequently point directly to the site of the pain with the 
hands. During dentition they feel about in the mouth, in hydroce- 
phalus and cerebral irritation they will pull at the hairs (but some- 
times also at the genitals), and in croup they press and rub themselves 
about the neck ; older children, when suffering from colic, press with 
their hands upon the abdomen, or when suffering from pain in the 
bladder, which is often caused by vesicants, upon the organ. When 
affected with worms, they will pick and bore at the nose and anus. 
Atrophic children keep their thumbs drawn inward and the hands 
shut firmly. The flexing and extending of the lower extremities by 
starts and jerks, attended by crying, are the ordinary signs of flatulence, 
and cease as soon as the flatus has been discharged. 

The examination of the pulse can only be carried out with success 
in a sleeping child. In one that has waked up suddenly, or has be- 
come agitated through much handling, the physician will find that he 
has to battle with insurmountable difficulties. The child seeks in 
every manner to twist itself loose from his grasp, and the firmer the arm 
is fixed, the tenser does the child make its muscles, and it often be- 
comes wholly impossible to feel the pulse. 

Various measures have been suggested by which we might be 
enabled to feel the pulse in a child, such as to allow it to suck at the 
breast or bottle. But the act of sucking always accelerates the 
respiratory and the cardiac actions, and for this reason no useful 
information whatever can be obtained by this method. It is best, 
therefore, to quietly approach the child while asleep, lightly com- 
press the radial artery with the end of the index-finger, and, when 
it moves its arm, accompany it in all its movements Avithout the least 
resistance ; after the removal of the fingers the child usually sinks 
again into a sound and lasting sleep. But if the restlessness of the 
arm continues, the examining finger should be withdrawn, because 
otherwise the child will surely be awakened, and no time is so unfa- 
vorable for examination by the physician as that after awaking 
from sleep. Tlie neglect of these precautionary measures will doubt- 
less serve to explain the reason why most authors state the pulse 
of the nursling infant to be so high, 130 to 140 beats per minute. 
Vallcix, physician to the Foundling House at Paris, has found the 
medium of the pulse in thirteen healthy sleeping nurslings, from 
three to twenty-one days old, to be 87 (minimum 7G, maximum 104). 



18 DISEASES OF CHILDREN. 

In twenty-four healtliy sleeping nurslings, I found the minimum 
92, maximum 136, medium 109 per minute. It is still more diffi- 
cult, on account of the smallness of the artery, to discriminate be- 
tween a hard and a soft pulse. Undoubtedly, our chief attention 
in nurslings should be directed to the rhythm of the pulse ; an un- 
rhythmical, interrupted pulse occurs in cardiac affections and cere- 
bral diseases. Great frequency of the pulse-beats in children has 
much less significance than in adults, for that condition is induced 
by the least excitement and the most trivial pain. Slowness of the 
pulse is observed in sclerema of the new-born, and in cerebral com- 
pression. In many instances before death the pulse is altogether 
impercej^tible for one or several days. 

The thermometric measurements in infancy and childhood are of 
the utmost importance as an aid in the diagnosis of diseases. It is 
not at all difficult to employ the thermometer in nurslings and young 
children who are seriously ill, but with older children, especially 
when they are only suffering from a slight indisposition, the phy- 
sician encounters considerable opposition to the use of the instru- 
ment. Few and incomplete thermometric measurements are of little 
value for the purpose of forming a diagnosis or a prognosis, while 
minute and prolonged examinations cannot always be carried out 
in private practice, especially where the children are unruly or bad- 
tempered. Moreover, the frequent disturbance of such a child tends 
to excite it very much, and it is questionable whether any good is 
accomplished by such a procedure. Still, the use of the thermometer 
in the treatment of the diseases of children is indispensable, though 
much valuable information may be acquired by the repeated appli- 
cation of the palm of the hand on different parts of the child's body 
(head, thorax, and abdomen), and thus approximately the tempera- 
ture may be ascertained. It may be observed here, en j^assant, that 
a very high temperature, even 107° F., is often met with in strong, 
robust children suffering from febrile complaints, without thereby 
rendering the prognosis necessarily lethal. [The examinations are 
best made by inserting the thermometer into the rectum or vagina 
of the child, having first lubricated the instrument with some lubri- 
cant substance, such as oil, vaseline, soap-water, etc. The instru- 
ment should never be put into the mouth of the child ; first, because 
it is not possible to cause the child to close its lips properly so as to 
entirely envelop the thermometer, and, moreover, in older children 
there is danger of the instrument being broken by the child bit- 
ing it. 

If the physician desires to take thermometric measurements in 
the sleeping child without waking it, or in one that is seriously ill 



RULES FOR THE EXAMINATION OF CHILDREN. I9 

without disturbing it, the instrument should be placed in the axilla, 
and, by pressing the arm tightly against the thorax of the child, the 
instrument will soon indicate the temperatui'e. In this manner, 
however, only an approximate degree can be obtained, the ther- 
mometer in the axilla marking from one-half to one degree less than 
in the mouth, vagina, or rectum ; a much longer time will also be 
necessary for the instrument to be retained in the former than in 
the latter places. For the purpose of avoiding all possible danger of 
transmitting infectious diseases from one patient to another, the 
thermometer should be carefully cleansed in some disinfecting solu- 
tion before and after using it. I have seen at least two lamentable 
instances occurring from the neglect of this precaution,] 

The examination of the respiratory organs in small children is 
attended by the greatest difficulties, occasioned as much by the 
smallness of the affected organs as by the restlessness and refractori- 
ness of the child. The physical examination embraces inspection, 
percussion, auscultation, and palpation, the first two of Avhich can 
only be performed during perfect quiet, but the last two even in cry- 
ing children. 

Inspection. — First of all, as regards the number and kind of respi- 
rations in children who have not yet passed the first year of life, 
it appears, from the very positive statements of the most conscientious 
authors, that upon this point no definite normal numbers can be given. 
These statements fluctuate between eighteen and thirty-five respira- 
tions per minute. Above all, we must remember that the respira- 
tions, even of healthy children, are not alike during sleep and wake- 
fulness. Only during sleep is respiration performed in a perfectly 
regular and rhythmical manner. Sixty experiments, which I instituted 
in twenty-two sleeping children from three to four weeks old, gave 
me, as a medium, 26.4 inspirations per minute. As soon as the 
children are roused and have become somewhat lively, the respira- 
tions are changed by every touch, every unusual noise, and every 
change in the light of the room ; the interval is longer than usual, and 
is followed by a few short, very quick or deep and slow breathings ; and, 
if the children now begin to cry at all, the rhythm wiU be entirely 
abolished ; in general, however, the respirations increase in frequency 
during crying. Owing to this great physiological variation, no 
diagnostic conclusion can readily be arrived at from any small devia- 
tions from the medium number. 

In children who have passed the first year of life, the respiratory 
acts arc more unifonii in the wakeful state. In pulmonary affec- 
tions, which occur extremely often in childhood, particularly lobular 
pneumonia and rachitic carnification, the breathing is accelerated 



20 DISEASES OF CHILDREN. 

fr(5m two to four fold, consequently to fifty or eighty in the minute, 
without any mechanical hinderance, solidification of large portions 
of the lungs with exudations being physically demonstrable. In later 
years, after the completion of the second dentition, certain diseases 
only abolish the rhythm, especially all those cerebral afiections which 
are caj^able of exercising a serious pressure upon the cerebral substance, 
above all, acute hydrocephalus ; furthermore, large cerebral tubercles, 
carcinoma of the brain, and sometimes also meningitis and cerebral 
hasmorrhage, if the amount of pus or blood upon the meninges has 
attained to a certain quantity. In these cases, the res]3iratory acts 
are remarkalDly irregular, alternately retarded and accelerated, deep 
or sighing. 

As regards the respiratory actions, we have in the healthy child 
abdominal respiration predominant, i. e., the diaphragm contracting 
stronger and firmer than the muscles of the thorax ; the upper part 
of the chest is almost entirely undistended ; the lower portion, how- 
ever, is all the more markedly expanded, so that more of a change of 
form of the abdomen takes place than of the thorax. The manner of 
breathing varies greatly in various jDCctoral diseases ; the various de- 
viations will more appropriately be spoken of in connection with the 
individual diseases. A careful inspection of the thorax is very im- 
portant, and often supplies many clews, even before the actual phy- 
sical examination has been commenced, which, on the whole, in the 
restless condition of the child, is often unsatisfactorily accomplish- 
able. 

Percussion of the infantile thorax is best executed without a 
pleximeter or hammer, finger upon finger. The excellent rule in 
surgery, to avoid using all instruments that can be replaced by the 
hand, is here all the more applicable, as children, especially those 
between two and three years of age, have an insurmountable dread 
of the hammer and pleximeter, whereas by gentle and tender man- 
agement they will readily allow themselves to be percussed with 
the fingers. Children carried about upright are best percussed in 
the arms of the mother. In these, the dorsal surface, upon which 
the greatest attention is to be bestowed, offers itself most conven- 
iently, and the youngest children most readily submit themselves 
to be percussed when they are in direct contact with their mother. 
Young infants should be percussed in the lateral decubitus, from which 
little opposition will seldom be encountered. That the hands should 
be warmed before they are laid upon the naked body of the child, is 
self e\'ident. Physicians who sufifer from cold and moist hands will 
not particularly succeed in the children's practice. 

TJie percussion-stroJce should he made absolutely softly, gently, 



RULES FOR THE EXAMINATION OF CHILDREN. 21 

and slowly, and should he continued long enough on one spot until 
there has been a chance to percuss in the moment of the deepest inspi- 
ration and most com,plete expiration / for this purpose, ten and even 
more blows will often be requisite. 

A forcible percussion, such as is requisite on the back of an ath- 
letic adult, is, on account of the elasticity of the thorax and the smaU- 
ness of the organs to be examined, never allowable in children. The 
percussion is not made plainer thereby, but other parts, generally the 
intestines, are made to resound ; and, besides, the child is instantly 
and surely frightened by strong blows. 

Percussion should be performed slowly, because the examiner 
always requires a certain amount of time to appreciate the sound 
produced, and to form an opinion of it. The most experienced 
ear is unable to detect the finer variations of the sound produced 
by the usual rapid thumpings. 

Tlie same place is to be percussed until the deepest inspiratory 
and expiratory moment is caught, because only by comparing and 
properly estimating the two percussion-sounds thus obtained, and 
which always differ from each other, is a thorough investigation of 
the percussed part possible. 

I must call special attention to a phenomenon which, in spite of 
its daily occurrence, has nowhere yet been properly estimated, and 
stm less satisfactorily explained, namely: when both lungs of a 
healthy child are percussed by way of comparison on the back, from 
birth up to the second and even the third year, there is found on both 
sides, so long as the child breathes calmly, and makes no noise what- 
ever, a sonorous, feeble, or strong tympanitic percussion-sound; as 
soon, however, as it becomes disturbed or restless, or when it resists 
the examination, and proclaims its unwillingness by a pressing out- 
cry, then the whole condition is suddenly changed. Instead of the 
equal sonorous tympanitic sounds of both sides, a moderately dull 
percussion-sound prevails over the left lung, and a flat, empty 
sound over the right lung as far upward as the spinae scapulae. 
But, if the percussion is now quietly continued on the same spot 
some seconds, or even for minutes, tiU it happens that a percussion- 
stroke coincides with the moment in which the child again inspires 
deeply, and, for that purpose, has to abandon the abdominal pressure 
till the completion of the respiratory act, the original normal percus- 
sion-sound is suddenly heard again ; it, however, lasts but a few 
moments, and is instantly succeeded by an empty, flat sound. 

If the percussion has once disturbed the child, and especially if 
it does not cease to cry with the violent abdominal pressure, and, 
so long as tliis pressure lasts, the phenomenon just described mav 
3 



22 DISEASES OF CHILDREN. 

be studied with the utmost advantage in any child under one year 
of age. 

The proximate reason for this diminished sonorous sound upon 
the entire dorsal surface is owing to the abdominal pressure, whereby 
the whole contents of the abdomen are compressed upward. The 
difference between the right and left sounds, namely, the completely 
empty, flat percussion-sound on the right, is explainable by the 
strong upward pressure of the liver, the size of which is still dispro- 
portionately greater in comparison with the rest of the abdominal 
organs. 

Upon the anterior surface of the thorax, and also on both sides, 
the changes in the percussion-sounds, originating from the action 
of the abdominal pressure, are also noticeable, but in a much less 
striking degree. 

The singular phenomenon just described, namely, the complete 
dulness posteriorly toward the right side, causes my confidence to be 
somewhat shaken in the histories of pneumonia in small children that 
we find so frequently in text-books and journals ; and the more 
so, as the dulness in those cases is always described to have been 
most intense posteriorly on the right side. Such physical investiga- 
tions only can be relied upon in which it is expressly stated that, 
during the investigation, the child respired perfectly calmly and 
quietly ; that it did not employ the abdominal pressure, and that the 
dulness detected then was also present during the inspiration, and 
could be distinctly discerned for several days. I am convinced that 
attacks of bronchitis, which in the first days of their existence are 
attended by some fever and dyspnoea, are regarded as cases of 
pneumonia in consequence of the observer's not being aware that 
the dulness which, under the circumstances described above, appeared 
on the right side posteriorly, is a normal physiological condition / 
this may also explain the successful treatment of and rapid recoveries 
from pneumonia. 

There is another phenomenon to be noticed in percussing the 
thorax of a crjdng child, namely, the so-called metallic tinkling. This 
sound a person may study upon himself at any time, by striking the 
sternum with the shut fist, and at the same time singing loud notes. 
Tlie tone is thus momentarily interrupted by a sound that has a metal- 
lic clang, and a pitch the same as the tone sung, which, directly after 
the blows have occurred, rings out in its original purity. Tliis sound 
cannot be confounded with cavernous metallic tinkling, and the hruit 
de pot fWe occurring in the adult, as it can only be produced during 
crying or speaking, whereas that arising from cavities is heard even 
when the patient does not utter the least sound. Metallic tinkling is 



EULES FOR THE EXAMINATION OF CHILDREN. £3 

never met with in children who respire quietly, for, in the first place, 
cavities in children under two years of age, as is well known, are 
of extremely rare occurrence, and in the second, even if they do exist, 
this sound can only exceptionally be detected by percussion. No 
diagnostic importance can therefore be ato-ibuted to it. 

The size of the thymus gland may be ascertained by percussion. 
If the manubrium sterni is carefully and quickly percussed as sharply 
as possible, a dulness will be detected, which decreases in circumfer- 
ence from month to month. By this examination the physician can 
frequently convince himself that many children have a large thymus 
gland, and yet never suffer from spasm of the glottis, and also that, in 
many children who suffer from violent spasm of the glottis (or what 
has been called asthma thymicum), a thymus gland cannot be found 
on percussion. 

Auscultation, in adults the most important part of the physical 
examination, offers in children fewer advantages, partly on account of 
their constant restless condition and irregular breathing, partly owing 
to the smallness of space and the propagation of the sound, favored as 
it is by the elasticity of the thoracic walls, and lastly from the fact 
that the infantile voice can neither be called into action nor suppressed 
at the wish of the examiner. 

In emaciated children, when the intercostal spaces present marked 
depressions, it is altogether impossible to adapt the stethoscope accu- 
rately, and hardly any child tolerates the auscultation of the anterior 
or lateral surfaces of its thorax with the naked ear, therefore it only 
remains for us to auscultate the back. But while in the adult we 
definitely know the space that is bounded by tracheal respiration, 
in children this is not the case. In healthy children we hear over the 
entire back, often even over the entire thorax, a loud expiration and 
a tubular inspiration, so that, although this condition, when met with 
in an adult, would make us unhesitatingly affirm an extensive con- 
solidation of the pulmonary tissues, yet it would not in children. We 
have not in these auscultations both the strongly-defined sounds of 
normal vesicular respiration, and the bronchial respiration, but over the 
greater part of the thorax a sound very much like bronchial breathing, 
and difficult to distinguish from it. Thus the main conclusion which 
in the adult we are able to form from bronchial respiration, namely, 
solidification of pulmonary tissue, is lost ; in children we have chiefly to 
depend upon a mere comparison of both thoracic moieties, upon which 
of the two it is most distinctly heard. Auscultation of the voice fur- 
nishes good cardinal points. The voice, it is true, consonates all over 
the infantile thorax, but where solidified pulmonary tissue exists, there 
it consonates so forcibly that the examiner believes he holds his ear 



24 DISEASES OF CHILDREX. 

against the mouth of the child, and that it cries directly into it. This 
sign is all the more valuable, as it is available in crying children, and 
therefore does not necessitate any particular care or loss of time in 
examining the child. 

Palpation is the simplest and most convenient method of exam- 
ining the infantile thorax. When the hand is laid upon the chest 
of a child, the temperature and moistness of the skin are immediately 
appreciated. Since thermometric measurement, owing to the restless- 
ness of children, is not applicable, in private practice in particular, 
it is therefore necessary for the physician to become accustomed to 
judge of the temperature of the skin as accurately as possible by the 
liand alone, for augmented temperature is the most important of the 
group of symptoms which we call fever, and our therapeutic pro- 
cedures in a great measure are conducted in accordance with it. 

Besides the above general advantages, the hand that is laid upon 
the chest also feels the fremitus of the voice, i. e., the vibrations of 
the thorax communicated to the hand, which originate with the voice, 
and disappear again as soon as it ceases. Tliese vibrations are most 
strongly felt at the spot where they originate, over the trachea and 
larynx, very distinctly along the spinal column, in the space between 
the scapulas, plainly in the lateral regions, and over and above 
the clavicles and the sternum, ^^^lere the heart and liver are in 
dir'ect contact wdth the chest, the fremitus is completely arrested. 
Ijayers of adipose tissue also weaken the vibrations. 

Now, these phenomena occur in every healthy child, but become 
modified as soon as a part of the pulmonary tissue undergoes solidifi- 
cation by compact tubercles or scirrhous infiltration, lobar hepati- 
zation or carnification. When, in the above afi"ections, the larger bron- 
chi, terminating in the solidified parts, remain permeable, the voice is 
felt much stronger than in health. Occlusion of a bronchus abohshes all 
fremitus over a corresponding portion of the lung. Fluid effusions into 
the pleural sacs, where the liquid keeps the lung from the ribs, also 
hinder us from feeling the voice. On the other hand, in tlie compres- 
sion of the lungs that necessarily results from that condition, the fre- 
mitus is much augmented over those parts of the thoracic walls 
against which the comjDressed lungs lie. 

In addition to the voice, the rhonchi may also be elicited by pal- 
pation. If the tenacious masses of mucus which fill the trachea and 
bronchi in the form of lamellse or trabeculae are set in motion by the 
respiration, a certain sound is produced, which is carried along the 
thoracic Avails farther and more distinctly than any other. On this lat- 
ter circumstance is based the erroneous supposition that these sounds 
originate where they are most distinctly felt. The higher up toward 



RULES FOR THE EXAMINATION OF CHILDREN. 25 

the trachea the vibrating mucus is situated, the more diffused are the 
sounds produced thereby felt over the thorax ; the smaller the calibre 
of the bronchus containing the mucus, consequently the nearer the 
periphery of the lung, the more circumscribed will the sound be on 
the thoracic walls. 

Palpation of the voice and rhonchi should never be omitted, and in 
restless children must even take the place of percussion and aus- 
cultation. 

These are the main points to which the physician has first to direct 
his attention in the sleeping or at least in the quiet child. Percussion 
should always be the last thing to perform, because by it the child is 
apt to be waked from its sleep. 

The examination of the abdominal cavity is perhaps still more im- 
portant than the examination of the thoracic, for in early life diseases 
of the intestines are by far more frequent than those of the lungs and 
heart. If, in the adult, percussion of the abdomen gives no reliable 
results, on account of the fluctuating gas in the gut, in the child, where 
this is of such frequent occurrence, it is of still less value. In all kinds 
of intestinal catarrh, the bowel is tympanitic, and distended, so that 
the liver and spleen, on percussion, appear to have perceptibly dimin- 
ished in size. 

Valleix, when he desires to examine the abdomen of a child, causes 
it to be brought suddenly to a bright window or near a light, on 
which the restlessness, as a rule, instantly ceases ; the child is attracted 
by the light, and gazes at it steadily for some time. This moment 
must be made use of to make a slow, increasing pressure upon the 
abdomen, to which the child will calmly submit so long as the pres- 
sure causes no actual pain. In this manner the abdomen of the 
youngest child may frequently be pressed so firmly as to touch the 
spinal column. If the pressure is really painful, the child will utter 
an agonizing cry and distort its features, which sometimes directly 
ceases again as soon as the pressure has been removed. 

Serous effusions into the peritoneal sac, which occur principally 
after scarlatina and in tuberculosis of the peritonasum, is difficult to 
detect in the supine position. The serum then sinks back into the 
posterior part of the cavity and the intestines float upon the top of 
the liquid against the abdominal walls, so that fluctuation can nowhere 
be discovered. But if the child be allowed to fcit up or to lie upon 
the belly, the serum sinks downward and forward, and is then easy 
to be detected by percussion and by fluctuation. 

The a7ius should be carefully inspected in every child. In every 
diarrhoea it becomes red, and forms a certain index of the severity 
and duration of the evil ; ou it also usually appear the first symptoms 



26 DISEASES OF CHILDREN. 

of congenital syphilis. The internal examination is not attended by 
any ditficulties whatever ; the little finger well oiled is readily intro- 
duced by a slow, rotatory motion, but this procedure always causes 
pain, and should only be performed when actual indications for it exist. 

The genitals also deserve, in all cases, to be closely scrutinized. 
They are reddened in diarrhoea, and the scrotum especially exco- 
riates very rapidly; and the female genitals secrete a larger quan- 
tity of mucus. The simplest manner of examining the urethra is 
by introducing a silver probe, bent hke a catheter, for boys, which pro- 
cedure is of service, as a remedy in many cases of strangury. 

The inner surfaces of the thighs are the best indices for judging 
of the fleshiness of a sick child. An indisposition, and particularly 
a diarrhoea of several hours' duration, makes the formerly firm, tense 
integument soft and somewhat lax, in twenty-four hours small folds 
form in it, and, if the disease continues, the adipose substance disap- 
pears so completely that, in place of the former symmetrical con- 
dition, flabby folds form, which, however, as the nutrition improves, 
fiU up again surprisingly quick, and the inner surfaces of the thighs 
once more display their former shape and sohdity. 

The examination of the mouth should never be omitted. By 
pressing slightly upon the chin the child will usually open the mouth, 
or a finger may be introduced and carried slowly backward between 
the cheek and gums, tiU it reaches the anterior border of the ascend- 
ing ramus of the lower jaw ; here the finger is insinuated between 
the upper and lower maxillae, and now the mouth may be opened to 
the required extent. By a little adroitness and practice it is very 
easy to examine with the index-finger the posterior pharyngeal wall, 
the posterior nares, the epiglottis, and even the glottis itself; such 
an examination will often give much important information in certain 
cases of diphtheritis, retropharyngeal abscesses, croup, etc. 

The tongue, in children, is even less "the mirror of the stomach" 
than in adults. Children Avith severe intestinal diseases very fre- 
quently have a perfectly normal red tongue, and conversely healthy 
children with a good appetite and regular digestion often exhibit a 
very white, or, at least, a tongue spotted with islands of white fur. 
Many parents so train their children from the earliest age, that they 
wiU put out the tongue whenever ordered, and accomplish some good 
by their obedience. The young ones, however, carry their good 
breeding so far, that they constantly put out their tongue, even 
upon the street, for the family physician, whom they often recognize 
at a distance, and to the general amusement of the passers-by. 
Teething children with swollen gums allow their mouths to be exam- 
ined very unwillingly, it is therefore necessary to become accustomed 



RULES FOR THE EXAMINATION OF CHILDREN. 27 

to examine both jaws as rapidly as possible by one sweep of the fin- 
ger, so that they may not thereby be irritated and disquieted. 

Finally, there are two sounds which we have to note in the exam- 
ination of children : the cry and the cough. 

Children cry only during the expiratory act. During inspiration, 
it is true, some single sounds occur, for instance, in spasm of the 
glottis. But these loud, long-drawn inspirations are always single, 
and, properly speaking, cannot be included in the description of 
" cry," for by this we understand a succession of tones quickly fol- 
lowing each other. The ordinary cry, therefore, takes place only 
during expiration ; it is loud, ringing, long-drawn, and, in children 
of equal age, of tolerably equal pitch : stiU the tone of the cry has, in 
ahnost every child, something peculiar, which cannot be more accu- 
rately defined than the variations of the human voice. A momentary 
disturbance of the circulation must always ensue during crying, be- 
cause the air in the lungs becomes compressed by the abdominal 
pressure, and can only escape slowly through the tense glottis, and 
not in comparison to the degree of its compression. After a deep 
inspiration, the child begins its cry by opening the mouth wide, 
when the tongue may sometimes be seen moving about in slight con- 
vulsions over the margins of the gums, the alse nasi become dilated, 
the eyes tightly closed, and numerous wrinkles form upon the cheeks 
and forehead, the face growing constantly redder, its veins, as well as 
those of the neck, become turgid, and the cry is prolonged to the 
utmost without renewing the inspiration. When this period arrives, 
it rapidly takes a deep inspiration, and thus brings about a momen- 
tary remission of the distortion of the countenance. These distor- 
tions last as long as the child continues to be agitated ; but, when it 
becomes pacified, the inspirations and expirations become uniform 
again, the wrinkles disappear from the face, a few slight short cries 
follow, the mouth gradually becomes closed, and a slight exhaustion 
foUows, which generally terminates in a calm sleep. Sometimes, 
three or four cries, in rapid succession, in one expiration, are fol- 
lowed by one long-drawn cry, which terminates jn quivering strains. 
Tliis cry has a great similarity to the bleating of the goat. It may 
also be remai'ked here, that infants under three months of age (and 
to these only is the preceding description applicable) never shed 
tears. 

The most important conclusions, as to the nature of the disease, 
to be drawn from the cry, are the following : children who suffer from 
pneumonia, pleuritis, or atelectasis of the lungs, never cry loud, or 
continuously ; they can only emit a low, painful moan. Chil- 
dren afflicted witn catarrhal, diphtheritic, or croupous laryngitis, 



28 DISEASES OF CHILDREN. 

are unable to cry at all, they are aphonic ; the milder degrees of ca- 
tarrhal inflammation of the larynx do not completely suppress the 
cry, but make it hoarse. Hydrocephalic children utter only shrill 
tones, and after each outcry relapse into their former drowsiness. A 
child ill with fever never cries continuously nor long, even when it 
suffers violent pains. Children suffering from otitis, deep abscesses, 
or when wounded, cry the longest and most violently. 

In the cough we have a very important index by which to judge 
of the state of the respiratory organs. If the child coughs loosely, 
loud, and without pain, it is very certain that we have only a simple 
bronchial catarrh to deal with ; if, however, it distorts the countenance 
when provoked to cough, if the cough is dry and low, and if it seeks 
to suppress it as much as possible, then it is equally as certain that 
we have to deal with an inflammatory affection of the lungs. Croup 
begins with a dry, barking cough, which but too soon gives place 
to a low aphonic sound. Pertussis consists of a long, spasmodic, 
jerking cough, interrupted by a protracted, loud, and sucking inspi- 
ration. Tuberculous children, in most instances, have a dry cough, 
which recurs at short intervals day and night. The cough of t^^phous 
patients is, in comparison with the great morbid alterations which we 
physically demonstrate on the lungs and frequently find after death, 
very insignificant and without severity. 

These are the principal peculiarities which the physician has to 
take into consideration in the examination of a sick child. Now, as 
regards the conduct of the physician, the utmost patience and gentle- 
ness are indispensable in his intercourse with children. Those from 
one to three years old are always the most difiicult to manage. 
Nvu-slings and children under one year are seldom very timid, and 
are easily qiiieted by some diverting noise. But older children 
often have an insurmountable shyness for every strange face. Such 
a child the physician must not approach immediately after enter- 
ing the room ; he should at first ignore the child's presence alto- 
gether ; should enter into a conversation with the parents or nurse, 
in a gentle voice, and finally gradually approach the child with 
some bright object, or with a piece of sugar. "When at the bed- 
side, the child should not be immediately uncovered, its abdomen 
felt and squeezed, and the physical examination instituted. Some 
questions suitable to its age are first put to it, its playthings are 
admired, or it is told of some new ones, and promised to be pre- 
sented with them, etc., etc. ; in short, it is necessary to be on 
friendly terms with the child before the undertaking of a regular, 
thorough examination can be thought of. In this manner, however, 
it is almost always possible to quickly gain the friendship of the 



NURSING AND CARE OF CHILDREN. 29 

child. If, with a friendship formed in this manner, a little seriousness 
and energy are allowed to be blended, much more authority will 
thereby be acquired in a moment over the child than the parents 
ever thought possible. Children, under such authority, aUow them- 
selves very quietly to be examined, readily lie down upon any side 
desired, take even the bitterest medicines without objection, and 
assist the medical examination in every manner possible. JSTever, 
and under no circumstances, should the attempt he made to bring an 
unruly child into obedience by harshness, by firmly holding it, and 
stiU less even by a slight blow. Such measures not only cause greater 
fear, and give rise to violent crying, but the physician will thereby only 
bring upon himself the aversion and even hatred of most narrow- 
minded parents — the class that usually have boorish and unmanageable 
children. On the other hand, if the physician in such instances re- 
tains his equanimity and mild voice, the parents will feel most dis- 
graced by the ill-breeding of their children. They then sometimes 
ptmish the child so severely that the physician, from a medical point 
of view, has to interfere, and then he will have gained an humble 
and submissive patient. In general, the principle wiU hold good 
that the more seriously sick the child is, all the more easily will it 
permit itself to be examined. 

To the commencing practitioner, inexperienced in the Pffidiatria, 
these observations may appear insignificant and unimportant, but, 
when he has once conducted himself in accordance with them, he will 
perceive that without these details a successful treatment would be 
clearly impossible, notwithstanding all his knowledge and skill in the 
methods of examination. 



CHAPTER III. 

NURSING AND CARE OF CHILDREN. 

TuE best nutriment for a new-born child is undoubtedly the milk 
of its own mother; if she cannot nurse, the milk of a wet-nurse ; and, 
if this is also unattainable, the milk of a domestic animal. 

In regard to the suckling of a child by its own mother, two ad- 
verse conditions are not infrequently met with, viz. : an inability of 
the mother to nurse ; and the existence of circumstances rendering it 
improper for her to do so. 

She cannot suckle, when she has insufficient or no mUk, when the 



30 DISEASES OF CniLDREX. 

nipples are wanting or are malformed, or wlien local diseases of the 
breast, abscesses or carcinomatous nodules, exist. Whether a moth- 
er will have milk and be able to suckle her child, is, in primi- 
parge, difficult to prognosticate. The size and firmness of a breast 
form no positive guide for that. Often young, healthy women, with 
well-formed and apparently physiological breasts, have no milk, while 
in feeble women, with previously flat bosoms, it is often secreted plen- 
tifully, contrary to expectation. Pregnant women, from whose breasts 
much colostrum flows, will be best able to suckle the coming child. 
In regard to this secretion, Donne divides pregnant women into three 
classes : to the first belong those who have so little colostrum that at 
the end of pregnancy it is only possible to squeeze out a few drops 
from the glands. This colostrum microscopically contains only a few 
milk-globules, and only a small number of colostrum-corpuscles. A 
small quantity of milk-secretion should, then, only be calculated upon 
after the confinement. 

The second class comprises those women who, it is true, secrete 
much colostrum, which, however, has the very same properties as 
that of the first class. It is just as poor in milk-globules and colos- 
trum-corpuscles, and a plentifully-secreted, though thin, but non- 
nutritious milk may, with probability, be expected after delivery. 

But if, in the third class, the secretion of the colostrum at the end 
of gestation is rich, milk-white, and mixed with yellow streaks and 
lumps, and many milk-globules, and colostrum-corpuscles are present, 
then we may prognosticate, with tolerable certainty, that the preg- 
nant one is destined to suckle her child, and will secrete sufficient nu- 
tritious milk. 

Total absence of the nipples is seldom met with ; frequently, how- 
ever, a depressed nipple is observed, for which usually a too high 
corset, in which the space for the chest is too small, is to blame. 
After delivery it is too late to improve these depressed nipples, and 
the child will uselessly tire itself out in the attempt at extracting 
the milk, and finally ceases altogether; much, however, may be 
done for this condition during the last months of pregnancy. The 
women should be made to wear very loose garments, and once 
every day should put the bowl of a clay pipe over the nipple, and 
suck with the mouth at its stem, or, still better, the caoutchouc breast- 
pump may be employed. JBouchut suggests, if the woman cannot 
tolerate this manipulation, for another person to use the lips in the 
same manner as the nurse often draws the breast of the parturient 
woman. 

Lastly, those benign, hard nodules, which occur so frequently in 
girls and young married women, but which are perfectly painless, 



NURSING AND CARE OF CHILDREN. 31 

should not be confounded with carcinoma of the breast. They are 
totally harmless, and disappear completely in the first few weeks after 
parturition, soon after the niu'sing is in operation. 

The second condition, i. e., circumstances rendering it improper 
for the mother to nurse her child, is much more difficult to explain. 
Feebly and tenderly-organized women, at times, bear the suckling very 
well, when they otherwise possess favorable external circumstances 
and the lacteal secretory function so necessary for suckling. In other 
cases, on the contrary, nursing acts upon strong, robust women, when 
poverty, anger, grief, or unhappy matrimonial circumstances, become 
added thereto, extremely unfavorably; they become emaciated and 
grow old remarkably early. Those mothers must absolutely be forbid- 
den to suckle their children, who suffer from arthritis, epilepsy, syphilis, 
chronic cutaneous diseases, and tuberculosis, or even if they have only 
an hereditary disposition to them. In hysterical women, wet-nursing 
has, by virtue of the extraction of the vital fluids, not only an injurious 
influence upon the health of the mother, on account of the influence 
of the nervous system on the secretion of the milk, but also upon the 
child. When the mother is at an advanced age, especially if she is a 
primipara, wet-nursing is of itself forbidden, by the want of milk ; at 
any rate, it is in all cases to be dissuaded from on account of the thin- 
ness or poverty of the milk. Acute diseases, exanthema, typhus, 
puerperal fever, etc., usually cause stoppage of the milk ; as long, how- 
ever, as it is secreted, the child should not be weaned. Such milk 
does not act injuriously upon the child, and its abstraction is, in all 
instances, very advantageous to the mother. 

When none of these evil conditions exist, it should be made every 
mother's sacred duty to suckle her own child. Frail constitution and 
smallness of statm-e cannot remove this obligation ; otherwise most of 
our city women would be exempt from it. Aside from all other cir- 
cumstances, the milk of its own mother always agrees best with the 
child, for it is an often-observed fact that the child of a feeble mother 
will prosper at the maternal breast and grow excellently, while a 
strange child, whose guardians had been misled by the good appear- 
ance of the first, which had been given this feeble mother for a wet- 
nurse, would thrive under no circumstances. 

If a mother cannot or will not suckle her own child, then a wet- 
nurse is always the best substitute. 

It is very difficult to prescribe general rules for the selection of a 
wet-nurse, because a number of local circumstances come into consid- 
eration here, which must, naturally, diff"er in diff'ereat cities and coun- 
tries. 

If the selection can be made from a number of women, who offer 



32 DISEASES OF CHILDREN. 

themselves for the situation of a wet-nurse, that one should always 
receive the preference which has given birth to, and at her own breast 
brought up, a robust, healthy child. If this can be confirmed by per- 
sonal or creditable evidence, we have the greatest guarantee that after 
the expected deliveries the nursing will proceed with equal regularity. 
It is alwaj's well to procure a wet-nurse who has been confined three 
or ibur weeks before the woman whose child she is to suckle, for in the 
first three weeks almost every parturient woman has a tolerable quan- 
tity of milk to display ; but, in many, the milk, after this period, de- 
creases from day to day, and thus, in case it is necessary to engage a 
wet-nurse who has only been confined a few days before, we may be 
compelled, in a few weeks, to discharge this expensive individual, on 
account of insufficient milk. Moreover, the sequelaB of parturition, and 
particularly those annoying and tedious abrasions of the nipples are no 
more to be apprehended in a woman who has already nursed several 
weeks. The advantages enumerated here, at any rate, outweigh the 
slight disadvantage that the milk of such a wet-nurse, by rights, belongs 
to a child that is several weeks old. On the whole, the chemical com- 
position of the milk in one and the same wet-nurse, and still more in 
different ones, is so changeable that it is merely a fortunate coin- 
cidence when the milk of a strange woman agrees as well with a child 
as that of its own mother. 

The best age for a wet-nurse is between twenty and thirtj'^ years ; 
still, many exceptions may be made to this rule ; girls under twenty 
years are mostly primiparae, and therefore as yet do not possess the 
necessary qualifications for wet-nurses. In persons who are more 
than thirty years of age, the metamorjohosis of materials no longer 
takes place with sufficient activity, such as is requisite to produce 
milk that is satisfactory in quality and quantity. The French physi- 
cians maintain that brunettes have a more nutritious milk than the 
blondes, of which, in Germany, I have not yet been able to convince 
myself. As regards the mammary glands, it is necessary that they 
should be of moderate size, should be covered with healthy integu- 
ment; the nipples should be two or three lines prominent, and on 
pressure of the mammae the milk shovild flow from the lacteal ducts 
in numerous fine streams. Formerly it was also insisted upon that the 
wet-nurse should have good teeth ; but this, on account of caries of the 
teeth having become so general, now seems to be entirely neglected. 
It seems to me much more important, however, that she should have 
healthy, firm, red gums. Pale, bluish, easily-bleeding or foul-smelling 
gums always give rise to a suspicion of poverty of the blood, or diffi- 
cult digestion, two conditions which in no way harmonize with wet- 
nursing. Among our people, the phlegmatic and submissive wet- 



NURSING AND CARE OF CHILDREN. 33 

nurses are the most desirable ; an imperious person can never serve as 
a wet-nurse in a house where several servants are employed ; for she is 
barely engaged before she makes them feel her unbearableness, and 
after several days seeks to drive them from the house. The finale of 
the whole scene is, that the peace-disturber is discharged, and the 
family physician, who is expected to have an expedient for every thing, 
has to procure another wet-nurse. Generally, country girls are pre- 
ferred to those from the city. If it were true that the morality in the 
country is greater than in the city, then this would no doubt be an 
important reason ; my experience, however, does not confirm these 
suppositions. In most country wet-nurses the additional evils often 
exist that they become seriously home-sick, cannot tolerate the city 
board and manner of living, and with difficulty become acclimatized, 
so that, notwithstanding their stronger formation and their more 
developed breasts, they render less service than a factory-girl or a 
city servant-maid. 

Before a wet-nurse is engaged she and her child must submit them- 
selves to an examination of their entire bodies ; the child must be well 
nourished, should be sufficiently fat for its age, and on no parts of its 
body should have the least suspicious-looking sore. The nurse should 
have the above-described qualifications of the breasts and gums ; the 
physical examination of the thoracic cavity should reveal no abnormi- 
ties ; she should be free from all kinds of ulcers, and the mouth, anus, 
and genitals, in particular, should be carefully examined for traces of 
syphilis. 

All these precepts only find their applicability when a selection 
can be made from several wet-nurses. When, however, as is frequent- 
ly the case in small places, a person must be content when he is able 
to find one in the whole vicinity that offers herself for that situation, 
any one may then be taken that is free from febrile diseases and 
syphilis, and suffers from no demonstrable tuberculosis, secretes a suf- 
ficient quantity of milk, and has healthy nipples. 

We now come to the important point, i. e,, the milk and its chemi- 
cal and microscopical qualifications. 

The specific gravity of human milk averages 1.032. If it is allowed 
to stand quietly for some time, a thick, rich in fat, yellowish-white 
stratum, the so-called cream, will form on its upper surface, while the 
fluid found beneath it, poorer in fat and therefore specifically heavi- 
er, has a bluish-white color. Fresh woman's milk is bluish white or 
pure white, has a feebly sweetish taste and alkaUne reaction ; but, 
when it is allowed to stand in a temperature not too low, it grad- 



34 DISEASES OF CHILDREN. 

ually becomes neutral, and finally reacts acid and forms in small 
lumps. 

The essential difference between woman's milk and cow's milk does 
not consist in the differences of the quantities of the milk-sugar and of 
the butter, but in this : that the casein of cold's milk, when it turns 
sour, curdles into large lumps, and even into a solid gelatinous 
mass ; whereas the casein of icoman''s inilk ahoays coagulates into 
small lumps and loose flakes. 

In the microscopic examination, fresh human milk presents itself as 
a clear liquid, in which, as in an emulsion, fat globules, which have been 
called milk-globules, are suspended. Milk-globules vary in size, most of 
them having a diameter of 0.0012 — 0.0020'", but if the milk is agitated 
a little, allowed to stand for several hours and then examined from the 
upper layer, along with the ordinary milk-globules, many large oil- 
globules will be found, the diameters of which increase to 0.03 or 0.04'". 
(See PI. II., Fig. 3.) 

By the microscope alone, without the aid of chemical reagents, it 
is not possible for one to convince himself that the milk-globules have 
proper enveloping membranes. However, the presence of an envelop- 
ing membrane ma}^ be easily demonstrated, and, in fact, in two different 
ways. The one method, that of Henle, consists in the application of 
diluted acetic acid, and observing the acidulated milk under the 
microscope. The milk-globules in consequence undergo such an al- 
teration, that, if they were only minute oil-drops, they would never 
be capable of manifesting. They become very much distorted, some 
caudated, otliers biscuit-shaped ; on most, however, a minute drop be- 
comes visible, which appears almost like a granule of the milk-globule ; 
to this minute drop new ones become added on some places, so that 
around the now diminished milk-globule an entire circle of fine drops 
occasionally forms. By the application of concentrated acetic acid, the 
milk-globules fuse together into large drops. The second method is 
that of -E Mitscherlieh, and consists in this : when fresh milk is agitated 
with ether, the milk remains unaltered, and the ether takes up only 
a small quantity of the fat. Were the milk a simple emulsion, it would 
surrender all its oil to the ether, and would itself be converted into a 
transj)arent, or at least a semitransparent liquid; if some substance is 
now added which jDossesses the power of dissolving the enveloping 
membrane, for example, caustic potash, or carbonate of the same, the 
ether then takes up all the oil, and an almost transparent liquid whey 
remains behind. 

Besides the milk-globules, other elementary substances occur in the 
milk, namely, colostrum-corpuscles or corps granuleux of the French. 
Physiologically they are only found in the first few weeks after the 



NURSING AND CARE OF CHILDREN. 35 

delivery ; they then diminish rapidly, and always reappear as soon as 
any sickness supervenes upon the confinement, or the nursing-woman 
is attacked by an acute febrile aifection. They consist of irregular, 
conglomerated, very, small oil-globules, held together by an amorphous, 
slightly-granular substance, and, according to Senle, are of 0.006'" to 
0.023'" in diameter. Ether dissolves these much more readily than 
those of the milk-globules ; acetic acid and caustic potash dissolve the 
granular intermediate substance, and disperse the oil-globules ; iodine- 
water dyes the colostrum-corpuscles intensely yellow. There is, there- 
fore, no doubt of these corpuscles being very small oil-globules em- 
bedded in an albuminous substance ; a granule and an enveloping 
membrane cannot be demonstrated. (See PI. II., Fig. 4.) 

Along with these principal elementary substances of the milk, some 
solitary epithelimn-cells and mucous corpuscles are also found in it ; they 
only occur in larger quantities in local affections of the mammary gland. 
Goaguldblefihrine occurs only in milk containing blood. 
Blood-corpuscles are seldom found in the milk, and ordinarily min- 
gle with it only when erosions of the nipples exist. Fungi and infu- 
soria are never found in fresh human milk. 

As regards the chemical composition we have here : (1), sugar of 
milk (OjjHjjjO^J, which in human milk is found from 3.2 to 6.2 per cent. 
Colostrum contains most of the milk-sugar (7 per cent.) ; its quantity, 
according to /Simori's investigations, diminishes from month to month ; 
it seldom, however, falls below 4 per cent. 

(2.) Jflit, Sutter. — Butter forms the contents of the milk-globules, 
and may be tolerably well isolated by destroying the enveloping mem- 
brane (by churning). The individual fats of woman's milk have not 
yet been subjected to accurate analysis, but this much is known — 
that they very quickly become rancid and form volatile oleic acids. 
The amount of fat in human milk is not constant. Simon found from 
2.53 up to 3.88 per cent, of butter; Clemon and Scherer on the fourth 
day after the delivery found 4.3 per cent., on the ninth 3.5 per cent., 
and on the twelfth 3.3 per cent. ; Chevalier and Henry 3.5 per cent. 
In the colostrum Simon found 5.0 per cent, of butter. It is a remark- 
able fact that, by milking or artificial sucking, the milk that exudes 
last always contains more fat than that which has flowed out first, 
the other elements remaining unaltered. As this observation was first 
made in cows, it was supposed that the milk commenced to separate 
itself already in the fodder, so that the watery portion was greatest 
in the teats and less in quantity higher up ; but, as Reiset also observed 
the same phenomenon in woman's milk, which at various intervals was 
extracted from the breast of a wet-nurse, the reason has therefore to 
be sought in some other cause than in the presumed mechanical cir- 



36 DISEASES OF CHILDREX. 

cumstance, since simple explanation of dependence by virtue of the 
position of the breasts cannot be entertained. 

According to my latest researches, the quantity of fat in woman's 
milk varies extraordinarily. I have succeeded in producing an ex- 
tremely simple optical milk-test, with which an accurate estimation of 
the amount of cream can be made in two or three minutes, and indeed 
with a very small quantity of milk. A detailed description of the in- 
strument and the applications that have hitherto been made of it, is 
to be found in an appropriate brochure^ " A New Mlk Test," F. Encke, 
1862. In this manner the quantity of fat can be surely ascertained, 
and, what is of still more importance, with merely a couple of cubic 
centimeters of milk. The method hitherto employed for ascertaining 
the quantity of fat in human milk consisted in filling a galactometer, 
graduated by a scale of one hundred lines, with the milk pumped out 
from the breast, up to the line, allowing it to stand quietly for twenty- 
four hours, and then to read off the thickness of the stratum of cream. 
Good woman's milk must show no less than three lines thickness of 
cream. This galactometer, however, has the disadvantages that the 
investigation can only be completed after twenty-four hours, and that 
it is often difficult and painful to pump out so large a quantity of milk 
from a wet-nurse's breast. With my optical milk-test both of these 
disadvantaares are avoided. 

Sugar of milk and butter contain no nitrogen, and are the so-called 
respiratory material of woman's milk. 

(3.) Casein is found liquid in woman's milk, so long as it does not 
react acid ; it becomes separated into light flakes as soon as a super- 
abundant amount of lactic acid has formed through the decomposition 
of the milk-sugar. The milk of a good wet-nurse should contain 3 to 
3.5 per cent, casein; the colostrum, however, contains a little more, 
nearly 4 per cent. It is very difficult and requires a long time to ascer- 
tain the chemical quantity of the casein, and therefore it may be ap- 
propriately omitted in the selection of a wet-nurse. Casein is the only 
nitrogenous substance found in the milk. 

(4.) The soluble salts of human milk are chloride of sodium, chlo- 
rate of potassa, and alkaline phosphates, and in addition to these 
also potassium and sodium, which are foimd combined with the 
casein. 

The insoluble salts are the phosphates of lime and of magnesia, 
which esiDecially belong to the casein, and traces of oxide of iron and 
of fluor. 0.16 to 0.25 per cent, of salts, on an average, are found in 
human milk; 0.04 to 0.09 per cent, of which are soluble. The quan- 
tity of salts in the colostrum is greater than in woman's milk at a later 
stage of lactation. 



NURSING AND CARE OF CHILDREN. 3Y 

V^ernois and Secquerel examined the milk of eighty-nine nursing' 
vromen, and furnish us with the following average numbers : 

Density 1032 

1,000 parts of milk contain: 

Water 889.08 

Sugar. 43.64 

Casein.... 39.24 

Butter . 26.66 

Salts .■ 1.38 

There are certain circumstances which possess a marked influence 
over the synthesis of the physiological milk, namely : 1, innervation ; 
2, the time that has elapsed since the confinement ; 3, the manner of 
dieting the wet-nurse ; and 4, the sexual functions. 

(1.) Innervation, — The injurious influence which anger, fright, 
pain, nervous attacks, etc., are apt to exercise upon the milk, has 
been long known. The chemical changes which take place here have 
been less accurately investigated. In this respect the mammary gland 
resembles the lachrymal gland, which participates in almost every 
mental excitement. It is a fact that those children who drink at the 
breast of a wet-nurse who is mentally excited, soon after begin to cry 
violently, sufi"er from colic, get diarrhoea, and are sometimes attacked 
by convulsions. Whether the milk can thereby become so poisonous 
that children after partaking of it will die, must be doubted. When 
we bear in mind that a disproportionately large number of children, on 
the one hand, in general die suddenly, and, on the other hand, that 
there are nurses who almost daily become angry, we would therefore be 
more inclined to believe in an accidental concomitance than in an actual 
poisonous milk. I once had an hysterical woman under treatment, who 
suckled her child, and was not a little surprised, when, after one of her 
hysterical attacks, I pumped out a couple of teaspoonfuls of milk from 
her breasts, to find this milk almost totally transparent, like whey, and 
devoid of all saccharine taste. For the whole of that day she did not 
allow the child to drink at her breasts ; and, twenty-four hours after, 
the usual, very thick, yellowish- white milk, rich in fat, was again 
present, on which the child throve amazingly. It is also Avell known 
that cows give much less milk than usual when they are milked by 
strange persons. It is even said that they sometimes \vill give no milk 
at all when they are irritated during the milking, or annoyed by the 
presence of strangers. This must be due to a sudden diminution of 
the secretion and partial reabsorption of the secreted milk ; for the 
milk cannot be voluntarily retained, since no muscular apparatus an- 
swering to that pvirpose exists. At any rate, it is evident enough 

from these statements that great attention must be bestowed upon 
4 



38 DISEASES OF CHILDREN. 

the psychical disposition of the wet-nurse, and that there are perfectly 
healthy, Avell-developed women who, nevertheless, are totally useless 
as wet-nurses. 

(3.) The time that has elapsed since the confinemeyit has a great 
influence upon the composition of the milk. The colostrum, or the 
first milk, in addition to the already-mentioned chemical bodies, con- 
tains also albumen, mucus, and large granular colostrum-corpuscles. 
The size of the milk-globules is still more unequal than is the case 
later on. Butter and salts are found in larger quantities than at a 
later period, and to this is due the slightly laxative effect of the colos- 
trum. The milk-sugar decreases in quantity from month to month, 
and finally remains at 4 pr. c. as a minimum. 

(3.) The articles of food of the wet-nurse, when they are insuffi- 
cient, materially diminish the quantity of the milk in general, and the 
solid component parts in particular, so that a hungering wet-nurse 
supplies but little and Avatery milk of a light sjDecific gravity. But- 
ter and casein diminish in the highest degree. 

Vernois and Hecquerel have made numerous experiments in this 
direction, and found the following numerical differences : 

In good nnti-ition. In average nutrition. 

Specific gravit}- 1,034.G8 1,031.91 

Water 883.86 891.80 

Solid component parts 111.14 108.20 

Sugar 42.97 43.88 

Butter 26.88 25.92 

Casein 39.96 36.88 

Salts 1.33 1.52 

It is difficult to decide whether individual articles of food make 
more milk than others, and, in this respect, no general rules can be 
established, because the assimilation of the various articles of food 
varies extremely in different individuals. This much, however, is 
certain, that the quality and quantity of the milk are not in exact 
relation to the amount of nitrogen contained in the food. A wet- 
nurse from the country, for instance, will give more and better milk 
when fed upon the coarsest meal and milk-diet than if she consumed 
the largest piece of roast-beef every day. The use of alcohol or 
alcoholic drinks imparts to the milk a stupefying qualification. The 
nurslings sleej) much, are soon affected with cerebral irritation, digest 
badly, and become emaciated. In countries where beer is a popular 
drink, the women consider it impossible for them to suckle without 
consuming two or three mugs of beer daily. Those that were ha- 
bituated to large quantities of beer in the unimpregnated condi- 
tion, may continue to partake of it during lactation ; they will produce 



NURSING AND CARE OF CHILDREN. 39 

by it no injurious effects upon themselves nor upon the child. But 
when wet-nurses first learn to drink beer during lactation, and strive 
now with aU their powers to consume a large quantity of it at one 
time, marked cerebral congestion and digestive disturbances are in- 
duced thereby, which, at any rate, have injurious effects upon the 
nursling. 

Many remedies, which have been administered by the mouth, 
were subsequently detected in the milk. Most of the salts soluble in 
water, if they have not produced a profuse diarrhoea, are found in the 
miU< again ; iodide of potassium may be most easily and decisively de- 
monstrated. The mUk is agitated with a little starch-flour, and a few 
drops of nitric acid are added to the mixture, when the starch will 
instantly become converted into the weU-known dark-brown iodine 
paste. Various coloring substances also pass over into the milk. In 
the milk of cows, fed with esparsette, a blue coloring matter forms, 
which is said to possess analogous properties to indigo. 

Absinthium (wermuth) makes the milk bitter, the ethereal oils of 
garlic and of the thymioe taint it with the odor of these vegetables. 
When a drastic purgative of any kind is administered to the wet- 
nurse, its effects, in most cases, will become apparent in the milk, 
and, through it, upon the child. The treatment of the nursling, by 
remedies administered to the mother, is, on the whole, a useless tor- 
ture to the latter ; when similar remedies are actually indicated, the 
child wiU surely be found to tolerate them just as well when they 
are administered to it in properly-divided doses directly from the 
medicine-glass, as when they have first been taken up by the circula- 
tion of the mother, and then secreted by the mammary glands in very 
small and certainly in not accurately definable quantities. 

(4.) The sexual functions have an undoubted influence ujaon the 
secretion of the milk. If the wet-nurse menstruates, her milk in 
general will be sparsely secreted, but its solid component parts do 
not decrease in quantity ; on the contrary, they become augmented. 
Butter and casein increase decidedly, milk-sugar and the salts demon- 
strably. The child thereby becomes somewhat restless, and displays 
the signs of disturbed digestion. But, after the termination of the 
menstruation, the former composition and quantity of the milk return, 
and for this reason it does not seem proper to immediately discharge a 
menstruating wet-nurse, as is so very frequently done ; it is much more 
advisable to wait for the recurrence of the catamenia, and then only 
to discharge the nurse Avhen the child remains indisposed for some 
time after the menstruation, and does not thrive in the same manner 
as before. 

If pregnancy recurs, the continuance of lactation is of itself pre 



40 DISEASES OF CniLDREN. 

liibited, because the secretion of the milk immediately becomes very- 
much diminished, and the milk again assumes the properties of colos- 
trum. If, in exceptional cases, these changes do not take place, the 
nursling must nevertheless be weaned, because, otherwise, the growth 
of the foetus will be interfered with in the highest degree. Whether 
a coitus, upon which no gestation follows, is in itself injurious, I am 
unable to say ; it does not seem possible, however. 

Rapidly-recurring pregnancies exercise an injurious influence upon 
the secretion of the milk. On account of the antemic and general hy- 
peraesthesia of the women which originates therefrom, but little and 
insufficiently-nourishing milk is generated. 

The milk, through certain diseases, undergoes important changes. 
Generally, in the milk of wet-nurses suffering from febrile affections, 
larger quantities of colostrum-corpuscles are found. Its quantity 
thereby decreases vastly in amount, or it dries up altogether. The 
solid component parts, however, do not disappear with equal rapidity 
with the watery, so that, at the invasion of a febrile disease, a milk, very 
rich in solids, is generated, and for that reason indigestions are very 
easily induced in the nursling. In general, the rule may be established, 
that the nursling should be left at the breast of the wet-nurse so long 
as she has milk, and the child suffers no very great digestive disturb- 
ances ; it is, however, necessary to premise that the disease must be 
not of a contagious character — nor an acute exanthema, nor petechial 
typhus, nor syphihtic affection. 

For the practical physician, it is entirely sufficient to prove the fol- 
lowing properties of the milk : (1.) He fills his graduated galactometer 
Avith milk, and allows it to stand quietly covered for twenty-four hours, 
at the expiration of which time the stratum of cream should comprise 
at least three lines of the glass in thickness. (2.) He tests the milk 
with blue litmus and yellow turmeric paper. The litmus-paper should 
in no case become red ; the turmeric-paper should turn slightly brown. 
(3.) He puts a few drops of the fresh milk upon the tongue. It should 
have an insipid and slightly-sweetish taste. (4.) He puts one drop 
of the milk under the microscope. If the wet-nurse has been con- 
fined for more than eight days previously, the colostrum-corpuscles 
and epithelium-cells should not be present at all, or only in very small 
numbers. The milk-globules ought not to be of too unequal sizes, nor 
be present in large quantities. 

In general, it may be remarked that the state of health of the wet- 
nurse, her digestion, her sleep, her respiration, her skin, and her geni- 
tals, deserve a much greater attention than the chemical and morpho- 
logical composition of the milk, and that it is more important for the 
physician to satisfy liimself accurately of a sufficient quantity of milk 



NURSING AND CARE OF CHILDREN. 41 

than to prove the qualitative proportions. The quantity of a milk- 
secretion may be ascertained by weighing the child both before and 
after nursing, by which it should always be found to have increased 
from three to five ounces. But, as these weighings are troublesome, 
and not very much liked in private practice, simply watching the child 
while it nurses will serve to inform us whether the nurse has sufficient 
milk or not. If the child does not exert itself very much at it ; if the 
milk runs out at the angles of the mouth ; and if, after half an hour, 
it quietly and contentedly forsakes the breast, one may be convinced 
that it has obtained a sufficient quantity of milk. 

If, now, one has had the rare luck to find a wet-nurse answering in 
every respect, the following precautions are to be taken to preserve 
her future good health. Warm baths are, for persons from the lower 
ranks of society, something so rare and unusual, that it does not seem 
advisable to allow the wet-nurse to take whole baths at once ; it is 
best to have her take several parts of baths in the week ; warm water, 
Avith soap and good-will, will accomplish a tolerable degree of clean- 
liness. If the wet-nurse has been used to warm-water baths before, 
they will also be harmless to her during lactation. The same holds 
good with river and cold sea baths. The rule should always be 
adhered to, not to alter the habits and manner of living of the wet- 
nurse, if it is only possible to carry them out in conjunction with a sen- 
sible house regime. The wet-nurse may partake of every thing, with 
the exception of highly-spiced and very salty food and alcoholic drinks, 
that is palatable to her ; and it is always best, if her manner of living, 
a couple of between-meals excepted, does not deviate from those of 
the family in which she has come to live. All her dishes must be 
well prepared and suitable to her taste ; for the rest, it is really super- 
fluous to ordain a detailed bill-of-fare. 

Her sleeping-room should be well ventilated, and she herself must, 
without regard to the weather, take daily exercise in the fresh air ; it 
IS only necessary to observe here, that, if she is not well and long 
known, she should never be allowed to go out alone. 

A great prejudice exists in the public mind against menstruating 
wet-nurses, and a few spots of blood upon their linen suffice to 
cause the parents of the nursling the greatest anxiety. The dan- 
ger, however, is not so great by far as it appears ; most wet-nurses 
menstruate but feebly and irregularly, and although during the cata- 
menial flow they have usually somewhat less milk, and although the 
children at this time, it is true, may be seized with colic pains, yet, in 
from one to three days, the whole process is over, and wet-nurse and 
nursling again enjoy the best of health. 

Two principles must be maintained and daily inculcated : 



42 DISEASES OF CHILDREN. 

(1.) The breast is no quieting remedy for the crying child, but it 
IS only to be given to it regularly every two or three houi's. Any 
restlessness that occurs during these intervals is no sign that the child 
is hungry, but Avill be found to be due to some other cause ; frequently 
to tight dressing, wet diapers, or the like. In the night a four hours' 
pause, for instance, from nine in the evening to one in the morning, 
suffices completely to allow the Avet-nurse to enjoy the first half of the 
night's rest. The ad'y-ice of some Pffidiatricars, not to put the child 
to the nurse's breast from evening till morning, I have not yet been 
able to carr}'' out. 

(2.) The wet-nurse should never be allowed to keep the child with 
her in bed. I am convinced that many of the mysterious sudden deaths 
of nurslings are to be explained by suffocation in the bed of the 
mother or wet-nurse. The nurses fall asleep while suckling the child, 
and either suffocate it by themselves or by the bedclothes falling 
upon it. A cautious mother should, therefore, never begrudge her- 
self the trouble to look after the wet-nurse several times a night 
and insist with the utmost firmness upon the latter's carrying out 
this rule. 

Many wet-nurses suffer from obstinate constipation, and, by hiding 
the evil, ultimately bring upon themselves actual digestive disturb- 
ances. They should therefore be instructed not to neglect it, but 
immediately to inform the parents of the child of it ; the cure is very 
simple, for the entire trouble may be removed by a few drachms of 
conf. sennge or boiled prunes. 

The wet-nurse ought to be treated with s^inpathy, and in a friendly 
manner ; the poor creatures are heartily to be pitied, notwithstanding 
their high Avages, Avho, by their OAvn fault, it is true, get so far as to 
give away their own child, and in its place take a stranger's to their 
breast ; such a service, if regarded in its true light, cannot be paid 
with money. 

Finally, the question arises, ^^Tien and how shovild the child be 
weaned ? 

The answer for this question but rarely depends upon the opinion 
• of the physician alone ; usually a number of external causes, or regard 
for the health of the wet-nurse or of the child, influence the determi- 
nation of the period for weaning. Here, too, as unfortunately in so 
many other things in the practice of medicine, the affair cannot be 
disposed of with a few nuinhers ^ many circumstances must be placed 
opposite each other, and carefully weighed. The most natural is mani- 
fest, to allow the child to nurse so long as it readily takes the breast, 
thrives upon it, and the wet-nurse does not suffer therefrom the 
least prejudicial effects in her health, such as weakness, pallor, emaci- 



NURSING AND CARE OF CHILDREN. 43 

ation, hypera3sthesia, etc. This condition in a healthy nurse a,nd a 
strong child lasts, in our climate, on an average, from four to eight 
months. Then the nurse perceives that the secretion of milk does not 
increase in comparison to the increasing growth of the appetite of the 
child, and consequently the nursling does not obtain sufficient nutri- 
ment. Now the period has arrived when the child may be allowed 
other nutriments besides the breast. Here, too, it is difficult to say 
whether this or that article of food is the most appropriate, and 
the rest injurious, for all children have not the same power of digestion 
and the same taste ; some, for instance, will take no cow's milk, nor any 
thing prepared with it, so long as they get the breast, if it is only once 
a day, while they will take the various beef-broths without much objec- 
tion ; others Avill take no meal-porridge, but only cracker-soup ; while 
still others will partake of no kind of milk preparations, but only of 
beef-broths, etc., etc. I therefore cause the commencement to be made 
with a thin fresh bread-and-milk preparation ; if in eight days this 
does not succeed, I try meal-porridge ; and if this is also unacceptable, 
then I resort to thin beef-broth and bread. Some one of these three 
preparations will be tolerated by every child if the breast of the wet- 
nurse is incapable of supplying sufficient nutriment. For four weeks 
the child gets one mess a day ; for four weeks more, two ; and for 
four weeks more, three times daily. In the mean time the child has 
learned to masticate the crust of white bread and to drink water, 
takes the breast but once during the night, and does not miss it 
very much when finally at night it gets lukewarm cow's milk in its 
stead. 

This is the surest and safest method of weaning a child. Often 
enough it has to lose the wet-nurse at once, or in a very short time. 
In that case it is especially important to take into consideration the 
dentition periods. If the child has happily just passed through a 
dentition period, so that it may be assumed with certainty that it 
will be free from the troubles of dentition during the coming weeks, 
then, in most cases, it will also bear the sudden weaning without any 
danger ; but, on the other hand, a profuse diarrhoea comes on in most 
cases, which often cannot be arrested, or from the eifects of which, 
at least, children suffer for months. As soon as a child has cut its 
upper and lower incisor teeth, Nature has assigned to it more solid 
food than the milk of its mother. At any rate, it is useless, and, for 
most mothers injurious, to suckle their children beyond the first year. 
In most instances they then wean themselves, because they do not 
obtain a sufficient quantity of milk from the breast at one time. I 
once treated an American lady, who still suckled her son who was 
tioo and a half years old, till one morning, when the strongly-devel- 



44 DISEASES OF CHILDREN. 

oped, robust child was called to be nursed, he very kindly re- 
plied, " I thank you, dear mamma, the nursing is too tedious for 
me!" 

If the mother herself is unable to suckle, and has not the means 
wherewith to hire a wet-nurse, there is no other alternative than to 
try artificial feeding. 

The following conditions are requisite for an artificial rearing : 
Care in the selection and preparation of the nutriments, great i:)a- 
tience and perseverance, the strictest accuracy, manual dexterity, 
and the highest degree of cleanliness. 

The best substitute for woman's milk is cow's milk, not because 
it resembles it most in composition, but because it can be obtained 
most regularly and easily at a low price. Those only who have de- 
voted some time to the quantitative examination of milk will be 
able to agree with me that the few per cents, more of casein and 
butter, and the few per cents, less of milk-sugar alone, cannot make 
the great difference which certainly exists between the nourishing 
of a child with woman's milk and cow's milk. Indeed, the secretion 
of the mammary glands, like that of the kidneys, has tolerably wide 
physiological boundaries, out of which some really fine medium 
numbers may be constructed. But, nevertheless, it does not follow 
from these averages that that milk is the best which stands nearest 
to the physiological average. 

Now, ever since the transmissibility of tuberculosis attained to 
such importance, it was natural to suppose that tuberculosis of the 
cow might be transmitted to human beings through the use of the 
milk. By a peculiar method of feeding sucking-pigs with milk 
from consumptive cattle, they were actually made tuberculous, and 
hence cow's milk in general has been deemed dangerous to the hu- 
man being. Although these facts deserve the utmost consideration, 
still they are not suflicient to exclude the use of cow's milk from 
the nursery. The numerous experiments with rabbits, sucking- 
2)igs, and the like, are by no means capable of rendering satisfactory 
conclusions for the human being ; moreover, the assertions that 
tuberculosis was produced in the human being by the use of milk 
and meat of consumptive animals always leaves room to suspect the 
existence of an hereditary taint, which is now so wide-spread among 
the masses. 

But, admitting that cow's milk is not devoid of danger, the same 
apprehension must exist in rearing a child by a wet-nurse. How 
often has it been noticed that a seemingly perfectly healthy wet- 
nurse, while wet-nursing an infant, has become consumptive with- 
out infecting the nursling ! 



b 



NURSING AND CARE OF CHILDREN. 45 

According to Goring's report, all Bavarian veterinary surgeons 
deny tlie likelihood of a baleful influence upon the human economy 
by the use of milk and meat of tuberculous animals. Some even 
o-o so far as to assert that the public executioners' families live upon 
such meat with no injurious results. Since nearly two pro mille 
of all the cattle in Bavaria are tuberculous, and many of the 
milch-cows, though in apparently perfectly healthy condition, are 
found to be affected with tuberculosis when killed, all the inhabi- 
tants, especially the peasant-children, whose chief article of diet 
consists of milk, ought by this time to be affected wdth tuberculo- 
sis, Nevertheless, under these circumstances, it is best to maintain 
the old rule, to use none hut boiled milk, since boiling destroys all 
spores, germs, and contagious particles. On the other hand, the 
assumption that milk of one cow is preferable to milk obtained from 
several cows is of little value, since in two-thirds of the affected 
cows the tuberculosis was not recognized during life, so that a large 
number of milk-consumers daily use a quantity of healthy milk 
mixed with that from tuberculous cows, in the proportion of, say, 
1 to 1,000. 

However, if the transmissibility of the disease is to be assumed 
to be possible, then it is less dangerous to partake of the infectious 
substance in a diluted than in a concentrated form. 

The important difference between woman's and cow's milk is, as 
already observed above, to be found in this, that the casein of woman's 
milk curdles in the stomach into small light flakes, forming a very 
loose jelly, while that of cow's milk coagulates into large, compact 
lumps, of which one may convince himself by causing a child brought 
up at the breast, and one artificially reared, to vomit a quarter or half 
an hour after the meal. This is easily accomplished by rapidly 
moving the child about, by frictions over its gastric region, etc. The 
loose flakes of the woman's milk are easily digested and assimilated ; 
the firm lumps of casein of the cow's milk, the infantile gastric juice 
is incapable of dissolving, they are thrown up again or wander 
through the whole intestinal canal as large, sour, undigested masses, 
irritating it in its entire length. Hence it all depends uj)on our 
ability of depriving the casein of cow's milk of this property, and that 
in a great measure may be accomplished by rendering it slightly 
more alkaline. For this purpose I have been in the habit of using 
for some time back a solution of carbonate of soda ( 3 j to water 
|vj), a teaspoonful of which is added to the milk at every meal. 
When the milk is boiled into a mess or porridge, I cause the solution 
to be added to the cold milk, and in summer the entire quantity of 
milk to be consumed in the twenty-four hours should be rendered 



46 DISEASES OF CHILDREN. 

alkaline immediately upon its arrival at the house, by adding a table- 
spoonful of the solution to every five ounces of milk. For very young 
children I cause, in addition, one-third of water and as much milk- 
sugar as can be taken upon the point of a knife to be added at every 
meal ; children over three months old drink cow's milk as it is, but 
always with the addition of the carbonate. I have seen dozens of 
children brought up upon milk thus prepared, and the majority have 
experienced no digestive derangements whatever. If the parents are 
sensible, they will abstain from giving the child all other Idnds of food 
but this milk for the first three months, and at the beginning of 
the fovirth month one other mess a day only may be allowed. The milk 
should be boiled immediately upon its arrival at the house, because 
the curdling is thereby delayed for some time. The best mess is pre- 
pared by soaking about an ounce of stale wheat bread for fifteen min- 
utes in some cold water, when the water Avill be foimd to be slightly 
acid ; the bread is then boiled into a uniform broth with six to eight 
ounces of alkaline milk, to which as much milk-sugar is added as can 
be taken upon the point of a knife. Meal-porridge is much preferred 
to this preparation, especially among the lower classes, for upon this, 
too, a great number of children thrive excellently well, and it is yet 
a question whether this preparation is not as harmless as the bread- 
jam. When four-fifths of the children brouglit up by hand get meal- 
porridge, and only one-fifth bread-mess, then, in assumed equal digesti- 
bility of both nutriments, four children fed upon meal porridge ought 
to sufi'er fi-om indigestion before one child fed upon the bread-mess 
finally becomes sick. 

Now, whoever is not aware that actually four times as many chil- 
dren eat meal-porridge as eat bread-jam, very naturally must form the 
idea that the former is by far less favorably tolerated than the latter. 
But until detailed statistical tables, conducted for years, demonstrate 
this circumstance in clear indisputable numbers, no one can maintain 
that thin meal-porridge is more injurious than bread. In addition 
to the ordinary wheat-flour, rice-flour or arrow-root may also be em- 
ployed. The method of using arrow-root is as follows : A teaspoon- 
ful of arrow-root is put into a porcelain vessel, as much cold water is 
added to it as will make it a fine dough, a cupful of boiling milk (or 
also water, or beef-tea) is then added, the mixture is stirred a little and 
allowed to boil for a few minutes till the whole acquires the consist- 
ency of a fine light jelly. 

By far the most rational of all substitutes for the mother's milk is 
undoubtedly the so-called Xiiebig''s soup, by which the great chemist 
has rendered an everlasting service to the PEediatrica. As is well 
known, we find : 



NURSING AND CARE OF CHILDREN. 4Y 

Blood-forming Culoric-generatlD; 
material. material. 

Iq woman's milk 1 3.8 

" cow's milk, fresh 1 3.0 

" cow's milk, skimmed 1 2.5 

" wheat-flour 1 5.0 

A mixture of wheat-flour and cow's milk may therefore be easily 
[)roduced that will present the same proportions of blood-forming and 
caloric-generating component parts as human milk ; wheat-flour, how- 
ever, reacts acid, and contains much less alkali than woman's milk, less 
than is requisite for the formation of normal blood, and, finally, a 
totally unnecessary labor, the conversion of the starch-flour into 
sugar, is imposed upon the infantile organism. It is, therefore, desir- 
able first of all to convert the starch-flour to the soluble form of susrar 
and dextrine ; this is easily accomplished by the addition of malt-meal 
to the wheat-flour. When milk and wheat-flour are boiled into a thick 
soup, and malt-meal is added to this still hot soup, the mixture in a 
feio mi7iutes hecomjes liquid and acquires a sweet taste ^ upon this 
and upon an addition of an alkali in order to neutralize the acid re- 
action of the wheat-flour is based the formation of Liebig''s soup. 

The method prescribed by Liebig himself is as follows : " Half an 
ounce of wheat-flour, half an ounce of malt-meal, and seven and a half 
grains of bicarbonate of potassa, are weighed off; they are first mixed 
by themselves, then with the addition of one ounce of water, and 
lastly, of five ounces of milk ; the mixture is then heated upon a slow 
fire, constantly stirring it until it begins to get thick ; at this period 
the vessel is removed from the fire, and the mixture is stirred for five 
minutes, is again heated, and again removed when it gets thick, and, 
lastly, it is heated till it boils. The soup is purified from bran by jDass- 
ing it through a fine sieve (piece of fine linen), and now it is ready for 
use. Barley-malt can be obtained at any brewery. First, it is sepa- 
rated from the impurities, and then ground in an ordinary cofiee-mill to 
a coarse meal. Care should be taken to use the common, fresh wheat- 
flour, not the finest^ because it is richer in starch-flour. Two parts 
of kali bicarb, crystal are dissolved in eleven parts of water, which 
will make a perfectly clear liquid. The troublesome weighing of 
the materials may be dispensed with, as a heaped tablespoonful of 
wheat-flour weighs pretty nearly half an ounce, a like tablespoonful 
of malt-meal, not quite so heaped, likewise weighs half an ounce, and 
an ordinary thimble filled with the solution of the bicarbonate contains 
nearly fifteen grains of the salt. Now, if in addition one ounce and 
five ounces of water are caused to be weighed ofi" in a beaker-glass by 
the druggist, and the height of the fluids is marked by strips of paper 



48 DISEASES OF CHILDREN. 

pasted on the outside, then every thing is conveniently arranged for 
a sensible mother ; the bicarbonate of potassa cannot be replaced by 
the bicarbonate of soda, as important potassa salts enter into the 
conformation of all our food, the milk and blood-corpuscles. The 
soup thus prepared tastes tolerably sweet, and, when proj^erly 
diluted with water, is tolerated even by nurslings. This soup, ac- 
cording to my own experience and that of many German physicians, 
is the best substitute for the mother's milk, and has visibly saved 
the life of many totally atrophied children. 

The greatest difficulty in large cities will always be the procuring 
of fresh, unadulterated milk. The milk obtained from general dealers 
is always far from being satisfactory, and it is absolutely necessary for 
one to be present at the milking and feeding of the cow, until he has 
become satisfactorily convinced of the honest dealings of his milk-pur- 
veyor. The milk used should be fi-om cows that are allowed to 
roam about in the open air for several hours daily and fed almost 
wholly upon green fodder. It will be cheaper in the end to procure 
milk from the country at an extra cost than to employ a wet-nurse. 
In recent years cow's milk, with the addition of cane-sugar, has been 
condensed into a syrupy consistence w^hich can be kept for some 
time without spoiling. This condensed milk is soluble in water, 
and can be readily prepared for instant use. When dissolved in 
ten parts of water we have a sweet milk, possessing even the aroma 
of fresh cow's milk. If a larger quantity is dissolved a trace of a 
precipitate remains behind, consisting of crystals of lactate of lime, 
which, being soluble in the juices of the stomach, are not deleterious 
to the digestion. A microscopical examination of the undiluted 
condensed milk shows beautiful crystals of milk-sugar, and between 
them a few tufts of lactate of lime. On the addition of a drop of 
water a countless number of globules of various sizes appear at once, 
which in no way differ from fresh milk-globules, the crystals of 
milk-sugar disappearing almost as rapidly. The appearance of the 
original milk-globule upon the addition of water distinguishes con- 
densed milk from all preparations of this kind that were formerly 
used in artificial feeding ; indeed, it is even possible to make fresh 
butter out of this milk if it is dissolved in seven parts of water, 
and churned in the usual manner, at a temperature of 63° F. 

Condensed milk has been found to answer admirably in the 
nursery. For the new-born babe, I cause one teaspoonful of milk 
to be dissolved in twelve of water, diminishing the quantity of the 
water gradually, so that by the end of the first year the child gets 
one of milk to six of water. I have seen many children thrive upon 
this preparation, without the addition of any amylaceous food. 



NURSING AND CARE OF CHILDREN. 49 

For the rearing of children in large cities this milk is of the utmost 
value. 

Recently, Nestle's food has come greatly in vogue. It is a baked 
cake powdered, consisting of wheat - flour, yolk of egg, and con- 
densed milk, containing 40 per cent, of sugar and milk-sugar, 5 per 
cent, fat, 15 per cent, protein e, and 30 per cent, dextrine. The 
starch is transformed into dextrine, not as Liebig's soup, through 
malt, but through superheated steam under high atmospheric 
pressure. It is preferable to Liebig's soup, owing to the readi- 
ness with which it is prepared for use, it being only necessary to 
mix one part of the food to six of water, and let it boil for a mo- 
ment ; by adding more water a preparation is obtained that can be 
used in a nursing-bottle. New-born infants do not always thrive 
well on this food, but older children, say from two months and up- 
ward, do very well on it. Nestle's food renders excellent service to 
nursing mothers who have not enough milk to satisfy the increasing 
demand of the child's appetite. 

[Jacobi, in his excellent monograjDh on the " Care and Nutrition 
of the Child," considers the mere addition of water to condensed 
milk insufficient, and advocates the use of some farinaceous broth. 
I have long ago observed that condensed milk, diluted with water 
only, does not give sufficient tone to the child. I have always 
recommended the addition of a decoction of barley or of oatmeal, 
according as the child shows a tendency to constipation or diarrhoea ; 
if the latter, I order that barley be used ; if the former, coarse- 
ground oats, boiled and strained. When it is necessary to resort to 
cow's milk, I likewise cause a decoction of barley or oaten grits, 
one-third to be mixed with milk two-thirds, and a lump of white 
sugar to be added to the mixture. In other cases, again, especially 
where there is a strong disposition to diarrhoea, I advise one-third 
or even equal parts of lime-water to be added to the milk. 

For the purpose of diminishing the amount of the casein in 
cow's milk, and still retain the full amount of its fats, Bledert ad- 
vises the addition of cream and sugar-of-milk, in proper proportions 
to the diluted milk. During the first month of life the infant should 
get a mixture consisting of one gill of cream, three gills of water, 
and about one-half of an ounce of sugar-of-milk ; after that time cows' 
milk is added, in proportion of one-third the quantity of water, 
gradually increased up to the sixth month, when other preparations 
may be substituted if deemed necessary. Considering the difficul- 
ties in the way of obtaining cream in large cities, and the variations 
in its consistency and freshness, not to speak of the cost, it will 
seldom be possible to feed a child upon this mixture entirely.] 



50 DISEASES OF CDILDREX. 

If, on account of existing unfavorable circumstances, it is im- 
possible to obtain such cow's milk for the child, other substances 
must be substituted, the usefulness of which, however, when em- 
ployed for a long time, is very problematical. Here belong veal- 
bi-oth with yolk of eggs, gruels, salep, and carrot-broth. The latter 
has been very favorably spoken of, and is prepared in the following 
manner : One ounce of triturated yellow carrots is mixed with six 
to eight ounces of water and allowed to stand for twelve hours ; the 
mixture is then pressed out through a cloth. The juice is mixed 
with pulverized wheat bread (one part bread to four parts juice), 
and boiled for a few minutes over a slow fire, and finally is sweet- 
ened with a little sugar. There are children who, under no circum- 
stances, tolerate cow's milk. These can exist for months upon 
carrot-broth, mucilaginous or beef soups with yolk of eggs ; they 
grow, however, but very slowly and never acquire a proper amount 
of flesh ; a trial must therefore be made with vei'y fresh, sweet 
milk ; often the absorption and assimilation of the milk succeed 
later, though at first it was not tolerated at all. 

The manner in which the nutriments are to be administered to 
infants is not immaterial. They may be fed, from the very first 
lay of life on, with a small spoon, or a cup having a snout, to which 
they readily habituate themselves ; but it is better to use a sucking- 
bottle, because with it the facial muscles are exei'cised in an equal 
manner, as in children at the breast of the mother. 

The simplest form of sucking-glasses is a common bottle of four 
to five ounce capacity, with a tolerably narrow neck, upon the 
mouth of which several finely-cut bits of delicate sponge are secured 
by a piece of gauze. These sponges should be changed several 
times daily, and are best preserved in pure cold water. When they 
are made to reach half an inch over the neck of the bottle, and if 
the gauze is made properly tense, they will imitate the form and con- 
sistence of the nipple. 

If these sponges are not good or elegant enough, the bottles 
may be provided with mouth-pieces of gold, silver, tin, or bone. 
Children drink very readily out of the perforated caoutchouc caps 
which lately have become so popular, and which are especially recom- 
mendable on account of their cleanliness. 

A very popular method of feeding infants is by the sugar-teat 
(Schnuller, Zulp). It is prepared by mixing pulverized sugar-crackers 
with milk or water so as to form a dough, which is then put into a 
linen rag and tied with a string so as to form a ball about the size of a 
small apple. This soft, sweet ball is put into the mouth of the child, 
when it cannot be quieted by the ordinary means, at which it instant- 



NURSING AND CARE OF CHILDREN. 51 

ly begins to suck, and thus may be kept quiet for bours. In general, 
nothing more can be said against cleanly-kept, often-renewed sugar- 
teats, than that the cheeks of the child, by the constant sucking, 
become enormously distended, and form disgusting protuberances 
when the mouth is closed without them. Usually, howevei', the 
contents of the rag, from its contact with the warm mouth, soon 
begin to ferment, the mucus of the mouth becomes acid, and directly 
upon that digestive disturbances supervene, and a fungous growth 
springs up upon the mucous membrane of the mouth, which only 
too often leads to a sorrowful end. It is therefore the duty of every 
physician to prohibit the use of the sugar-teat whenever and wher- 
ever possible ; but this, in fact, can be more easily advised than 
accomplished ; if we only think of the condition of a poor woman 
who all day long is plagued by a large number of small children, 
and at night, when she and the other members of the family ab- 
solutely i-equire rest, the crying child will not leave her arm. She 
will then certainly say • " The physician gives good advice, not to 
use the sugar-teat ; he, however, is not obliged to carry this crying 
child about all through the night ; " thus not one woman out of a 
hundred will withhold it from her child. 

From the lower classes it will hardly ever be possible to eradi- 
cate this fermenting ball, and among the better classes the cliild bas 
a wet-nurse, or at least proper care, and the sugar-teat is renewed 
often enough, whereby it is generally rendered harmless. So much 
for the nutrition of the first year of life. 

In the second year, the children may be allowed some soft, finely- 
cut meat. If they have no diarrhoea, nor are predisposed to it, they 
tolerate fresh ripe fruit excellently well ; on the other hand, boiled 
green vegetables and husk fruits very generally cause them indiges- 
tion. For a child two years of age, for example, I prescribe the 
following diet : Mornings, between six and seven o'clock in sum- 
mer, or between seven and eight in winter, milk-gruel ; between 
nine and ten o'clock, a piece of wheat bread with very little butter 
on it ; twelve o'clock, well-prepared beef -soup, meat with a little 
gravy, or potato-broth, or in place of the meat a meal-broth prepared 
with eggs, but with very little fat, green vegetables very rarely and 
in very small quantities ; afternoon, between three and four, bread 
and milk, in summer bread with fruit ; evening, at seven, beef- 
soup or milk-broth. Sugar, in general, agrees very badly with 
children, and it is highly important for their digestion to habituate 
them to it as little as possible. After the children have passed the 
third year they tolerate all kinds of vegetables, and may, when oth- 
erwise well brought up, very appropriately be allowed to eat at the 



52 DISEASES OF CHILDREN. 

table with the family ; it is only necessary to refuse them very salt, 
sour, and highly-spiced victuals, of all others they may partake in 
moderate quantities. Children should not be allowed to taste wine 
till they are fourteen years old, even beer is absolutely unnecessary, 
as likewise are tea and coffee. Home-made rye bread should be 
substituted for the ordinary wheat bread. It is well to cause chil- 
dren to eat the entire meal off one plate. They should consume all 
the soup allowed them before they can obtain any thing from the 
next dish. Aside from the labor saved by not repeatedly changing 
the plates, children thereby acquire the good qualification of learn- 
ing to eat every thing, and not to become lickerish. 

If we now take up the care of children, we encounter, first of all, 
the culture of the skin. The vernix caseosus of the foetus cannot be 
washed off with water, but must first be mixed with some kind of fat, 
butter, lard, or pure oil, and may then be readily wiped off with a 
soft cloth. Infants should be bathed daily for ten minutes, in water 
of 92° F. Local affections do not sufiice to counteract this rule ; but, 
in general febrile diseases, the bathing must be suspended. The stay 
in the water and the variations of the temperature, which in the un- 
dressing and in the rubbing of the children dry cannot be avoided, 
increase, as a rule, the heat of the skin and induce a higher degree 
of weakness. 

After the first incisors have cut thi*ough, the temperature of the 
water may be gradually reduced to 86° F. In the first year of life it 
is not advisable to employ cooler baths. In the second year, when 
the children have less frequent movements from their bowels, and 
they begin to get cleanly, it is no more necessary to bathe them 
every day ; three or four baths a Aveek, in water 84° or 85° F., are 
sufficient. From the third year on, two or three baths weekly, in 
summer, daily river or sea baths, will keep the skin properly active. 

Children should be taught the art of swimming ; it is very useful 
and very invigorating to the health of both sexes. The culture of 
the skin not only requires cleanliness, but also the prevention of 
too great changes of its temperature, and this is accomplished by 
garments and warming. 

At the first dressing of the new-born, attention should be paid (1.) 
To the umbilical cord, that it is in no way dragged upon ; (2.) That the 
chest and abdomen are wrapped in such garments as will not hinder 
the respiratory acts that have so recently been established ; and (3.) 
That the upper and lower extremities are allowed to assume their natu- 
ral flexions. No child should be carried about upright, until it is itself 
able to raise its head and rotate it a little. The physician should be 



NURSING AND CARE OF CHILDREN. 53 

very cautious in advising that the child should be inured by the aid of 
light garments. It certainly cannot be denied that children inured in 
early life develop more rapidly and stronger, are seldom ill, and readily 
surmount a disease they may have acquired ; on the other hand, how- 
ever, it must also be admitted that many intestinal and pulmonary af- 
fections of children have been induced by a too rapid change in the 
temperature or by insufficient covering of the breast and abdomen. 
When the anxious parents have at last been prevailed upon to resort 
to the inuring method, and the child subsequently falls sick, the bit- 
terest reproaches, and not unjustly, will be heaped upon the physician. 
I therefore always resort to the expedient, never to disparage light 
garments wherever I meet with them, nor to absolutely insist upon 
them. Neither can unreasonable excesses of too warm or too cold 
garments be tolerated. When children learn to walk, they should 
have shoes with tolerably broad soles, which should be at least half an 
inch larger than the foot. Vain mothers begin at a very early period 
to direct their attention to the formation of a slender waist for their 
little daughters, which of course cannot be prevented in many cases ; 
for motherly vanity is a vexatious enemy to the rational physician. 
Finally, as regards the nursery-room, the child in the first eight 
days of its existence should be kept in a half-dark room, which is 
gradually allowed to become brighter, till finally, after fourteen days, 
the young eyes are perfectly accustomed to the light, and may be ex- 
posed to it without harm. From this time forth the nursery should 
be bright ; it should have at least two windows, the floor should 
be painted or covered with oil-cloth, so that no water should jDerme- 
ate it, and the stove should only be used for heating the room and 
not for cooking. For the purpose of thoroughly ventilating the 
room the windows should be kept open one-half or one hour daily, 
during which time the child, of course, is to be removed to another 
room. Fresh air is undoubtedly an absolute necessity for a robust 
development. Children born in summer should be taken out in the 
air from the second or third day on ; in winter, however, eight or 
ten weeks at least should be allowed to pass by before they can be 
carried out on a sunny noonday. Older children can never be out 
too much in the fresh air ; the earlier they are sent out, and the later 
in the day they are called in, all the better do they develop. In 
cities, the physician therefore finds it necessary to insist with the 
utmost energy that families should hire themselves gardens or shady 
grass-plots, where children may remain undisturbed the entire day. 
Promenades in public places, so much in favor with the nursery- 
maids, cannot in any way replace the undisturbed enjoyment of the 
child in a private park. 



PART II 

SPECIAL SUBJECTS. 



CHAPTER I. 

DISEASES OKIGINATING DIRECTLY IN CONSEQUENCE OF DELIVERY. 

Although, in a discussion on the diseases of children, it appears 
perfectly conformable with the purpose to adopt the plan of the latest 
works on Special Pathology, to simply take up the diseases of one 
part of the body after another, and not to base the classification upon 
the nature of the pathological alterations, still in the " Paediatrica " 
we meet with a class of affections which have a definite physiological 
connection, and therefore must also be jointly treated of before all 
others. It is those diseases which are indebted for their origin to the 
act of the delivery, and to the transposition of the child from the 
uterus into the atmospheric air alone. Here belong : (A) Asphyxia 
of the new-born ; (B) Atelectasis of the lungs ; (C) Cephalgematoma 
of the new-bom ; (D) The pathological conditions of navel ; (E) Tris- 
mus neonatorum; (F) Sclerema; (G) Melaena; (H) Icterus of the 
neAV-born, and (I) Ophthalmoblennorrhoea of the new-boni. 

A.— ASPHYXIA NEONATORUM. 

Syncope of the new-bom, or asphyxia (from a privativum and 
<^0i'?'f, the pulse), is a condition in which the inspiratory muscles after 
the delivery do not contract at all, or only imperfectly, and the breathing 
therefore does not commence. The movements of the heart continue 
here tolerably rhythmical, although they are feeble and not always per- 
ceptible, and only heard on auscultation ; the name asphyxia does not, 
therefore, seem to have been very happily selected for this affection. 
Two different forms of asphyxia are distinguished in the new-bom ; in 
the one form the children are cyanotic, usually they are very large 
and strongly developed, the integument is infiltrated, the tongue 



DISEASES CONSEQUENT ON DELIVERY. 55 

thick and blue, protruding from the mouth, the eyeballs project from 
their orbits, and the cardiac beats are feeble and unrhythmical. This 
form is also called asphyxia apoplectica, because it is probably due to a 
congestion of the brain, in consequence of imperfect action of the 
heart. In the other form the children are deathly pale, the extremi- 
ties hang down powerlessly, the lower maxilla drops down upon the 
sternum, the cardiac impulse and the pulsations of the umbilical cord 
are irregular and barely to be felt, the respiration is either totally ab- 
sent, or the thorax at short intervals rises short and spasmodically, 
and the meconium flows off involuntarily. The respirations constantly 
grow more infrequent, the cardiac beats feebler, and death usually 
ensues in a few hours. Between these two principal forms there are 
transitions which do not reflect perfectly either of the delineations 
just sketched ; in general, however, they are rare. 

Etiology. — Asphyxia has various causes. It may originate from 
compression of the umbilical cord against the pelvic walls, or the cord 
is wound around the neck of the child, or the placenta has become 
prematurely detached. The skull may have sufi'ered in its passage 
through the narrow pelvis or from the forceps, or the air-passages are 
plugged up vnth blood and mucus. Finally, early deliveries, feeble 
parents, and especially exhausting diseases of the pregnant mother, 
are known to be causes of asphyxia. Compression of the larger blood- 
vessels of the neck can only induce the apoplectic form, because a 
pressure that will merely make the arteries of the neck impermeable 
can scarcely produce asphyxia, as the more superficial cervical veins, 
with thin coats directly beneath, will only suffer. The flow of the blood 
to the head does not thereby become arrested, its return only is 
hindered. 

Compression of the navel-string, on the contrarj^, exercises an in- 
fluence over the umbilical vein before it does over the arteries ; more 
blood flows, therefore, from the foetus than to it, and anasmia vnth ex- 
haustion, and, finally, the so-called asphyxia nervosa, can only result 
from this condition. 

Pathological anatomy does not here supply any constant results. 
At the autopsy, nothing but a still tolerably complete fetal circula- 
tion is found, and, in particularly violent deliveries, or very unfavor- 
able pelvic disproportions, extravasations of blood between the me- 
ninges or in the brain itself. 

The course of this evil, as may of itself be understood, must be a 
very rapid one ; if no regular respiratory acts and distinct cardiac beats 
take place in a few hours, life will cease altogether, which termination 
more frequently occurs in the nervous than in the apoplectic form. 
Very often, with proper assistance, the respirations are established 



56 DISEASES OF CHILDREN. 

after soine time, the beats of the heart become stronger and more 
rhythmical, and the cyanosis in the one form, as well as the ab- 
normal pallor in the other, disappears completely. 

Therapeutics. — The treatment depends mostly upon the cause. 
First of all, the mouth should be thoroughly cleaned, and this is best ac- 
complished with the finger. By touching the palate and epiglottis, 
slight acts of choking and coughing are induced, which alone may suf- 
fice for the establishment of the respirations. If nothing was achieved 
by the cleaning of the mouth, then, in the cyanotic form, two table- 
spoonfuls of blood should be allowed to flow from the severed funis. 
If the cord does not bleed any more, all further attempts at abstrac- 
tion of blood must be renounced. Pale children very naturally toler- 
ate no loss of blood, and are rather to be guarded against it by care- 
fully tying the cord. A very simple and always handy remedy is, a 
few slaps ^^'ith the open hand upon the buttocks. Partly from the 
pain, partly from the shock, very useful reflex actions of the respiratory 
muscles ensue. If this procedure is also inefiiectual, the child should 
be put in a warm bath, taken out in a few minutes, swung up and 
down several times, and then put into the bath again. A beneficial 
stimulation of the skin ensues from these alternate warmings and cool- 
ings of the child. Irritating fluids may also be dropped upon the chest, 
among which, vinegar, brandy, ether, and Cologne water, are the most 
useful remedies. A very much hked, often praised, and then again dis- 
carded procedure is the direct inflation of air. For this purpose, the 
mouth and nose having been first cleaned, the physician applies his own 
lips to the open mouth of the child and blows, when natin-ally the air 
will come out at the nostrils of the child ; if they are so permeable, the 
physician should compress them with his thumb and forefinger and 
then blow in air anew. It is a great error to supjiose that any air is 
forced into the lungs by this method ; in most instances, the epiglottis, 
through the distention of the mouth with air, becomes depressed still 
more firmly upon the larynx, and then all communication between the 
mouth and lungs is completely cut off. Still, the irritation originating 
from the distention of the mouth may possibly have a similar effect to 
that produced by touching the glottis or tickling the fauces. 

If it is really desired to blow air into the bronchi, then Chaussier's 
instrument especially constructed for that purpose should be introduced 
into the trachea, the epiglottis having been pre\nously elevated by the 
point of the index-finger. Many and renowned obstetricians, however, 
discard the inflation of air altogether, and experiments performed upon 
new-born animals, which have been artificially asphyxiated by immer- 
sing them in warm water, also speak against it. It is rational to laj' 
the child upon the right side, Avith the upper half of the body slightly 



DISEASES CONSEQUENT ON DELIVERY. 57 

elevated, because by that the right auricle will come to lie downward, 
the left upward, and thus the blood that has entered the right auricle 
will have to mount straight upward if it desires to reach the left 
auricle directly through the still open foramen ovale instead of passing 
downward into the right ventricle. This posture may facilitate the 
closure of the fetal passage by the valve. Electricity will always be 
the surest means of causing the inspiratory muscles to contract. And, 
as the inspiratory muscles can only dilate the thorax at the expense 
of the lungs, the alveoli must therefore become filled with air, which, 
if it once properly fills and distends them, cannot escape again so 
rapidly, and will continue to act more and more as a stimulus for re- 
peated inspiratory movements ; the greatest difficulty which we have 
to contend with here is that there is " periculum in mora," and that to 
produce an electric current always requires a certain amount of time 
and knowledge which can hardly be expected of a midwife. 

All these attempts at animation are to be persevered in so long as 
the beats of the heart can still be perceived by auscultation. Not un- 
til these have been inaudible for several minutes may we abstain from 
all further attempts and pronounce the child dead. If we succeed at 
all in saving an asphyxiated child, then we usually accomplish it in 
one or at the most in two or three hours. 

B.— ATELECTASIS PULMONUM. 

If the inspiratory muscles do not contract sufficiently and regularly 
after the birth of the child, the lungs will also be but imperfectly and 
irregularly distended ; in some parts the alveoli will retain their fetal 
condition ; they will be airless and remain collapsed. This anatomo- 
pathological condition is called Aielectasis (from a priv., rtkoq^ the 
end, and ^ UTaiq, the dilatation). 

A whole lung or an entire lobe is seldom found affected ; gener- 
ally a few scattered lobules, especially posteriorly and downward, 
are observed to be atelectic ; they are sharply defined in both lungs, 
dispersed throughout the parts that contain air, are bluish-red in color, 
and compact, do not crepitate on pressure, and sink in water ; the cut 
surfaces are smooth, regular, and not granular. The atelectic por- 
tions of a lung may be easily inflated, but these inflated parts still re- 
main of a darker color than of that by which they are surrounded. 
Atelectasis is satisfactorily differentiated from lobular pneumonia, by 
this possibility of inflation of the atelectic parts. In addition, the 
passages of fetal circulation in most of these children are found still 
pervious ; no trace of inflammatory exudation, however, is to be detect- 
ed in any part of the lungs. 



58 DISEASES OF CHILDREN. 

Symptoms. — Generally, the children come asphyxiated into the 
world, or at least they breathe from the time of birth but super- 
ficially and imperceptibly ; their voice is characteristic of the evil. 
They are neither able to cry loud nor continuously, but will only 
utter a few single, Aveak, moaning cries, and are also unable to suck 
actively or continuously for any length of time. Sometimes they 
are temporarily cyanotic, sleep much, and have a pale, cool skin. 
The pupils act slowly, are slightly dilated ; the pulse is feeble and 
slow. The percussion-sound of the thorax, when the atelectasis is 
not very extensive, is scarcely ever altered, in general somewhat less 
sonorous than in healthy new-born. Owing to the slight motions of 
the thorax, the respiratory sounds are naturally very feeble. Bron- 
chial respiration is scarcely ever heard over the atelectic portion of 
the lung ; crepitating rhonchi, however, may sometimes be detected. 
If this, condition has existed for several days, spasmodic contraction 
of the facial muscles and general convulsions come on, the respira- 
tory and circulatory movements constantly grow feebler and slower, 
the skin becomes cooler, and the children either die by degrees, or 
expire suddenly during a severe tonic or clonic convulsive attack. 

Causes. — (1.) Asphyxia and all the conditions mentioned in con- 
nection with it. Atelectasis itself may be regarded as a milder de- 
gree of protracted asphyxia. (3.) Premature and feeble children. (3.) 
Authors also consider the inhalation of too cold air as a cause ; it is 
much more probable, hoAvever, that pneumonia originates from the in- 
halation of cold air ; and (4.) Too rapid and easy deliveries are stated 
to give rise to atelectasis. Atelectasis acquired some time after 
birth will be sjDoken of further on, in connection with pulmonary 
aflPections. 

Treatment. — The treatment is precisely the same as for asphyxia. 
As a prophylactic, it is of importance to cause every child, in the first 
moments of its life, to cry loud and continuously, for the purpose of 
which the remedies recommended for asphyxia are the most appro- 
priate : inflation is totally useless here, but the utmost benefit is 
derived from the cautious application of electricity to the pectoral 
muscles. As regards general rules, the children should be confined 
to a room of uniform temperature, of at least 59° F., and be kept as 
warm as possible, by Avarm garments and bottles filled with hot water ; 
their attitude should be changed frequently, and they should be car- 
ried about. They should not be fed w4th a spoon, but be made 
to suck, even if it costs them some exertion, because deep inspira- 
tions also originate through that. I once used the emetic recom- 
mended by Jorg, pulv. r. ipecac, gr. ii, but with an unhappy result, and 
since then confine myself to tickling the palate and epiglottis with 



DISEASES CONSEQUENT ON DELIVERY. 59 

the finger, once or twice daily, which induces violent retchings, fo 
lowed by correspondingly deep inspirations. 

An attempt has also been made to imitate the respiratory acts by 
external pressure ; the extremely flexible thorax of the new-born is, in 
this procedure actively and gradually compressed with the hand, the 
back of the child resting upon a firm support. Neither from this 
measure have I seen any favorable results, which in fact could scarce- 
ly have been expected, for these jerking compressions of the thorax 
have no more resemblance to the inspiratory movements than the 
corking of a bottle with its opening. 

Q.—CEPEAL^MATOMA.— BLOODY TVMOR OF THE HEAD. 

Symptoms. — The bloody tumor of the head, cephalsematoma (from 
fj KE<j>a^, the head, and alfia, blood), also called thrombus neona- 
torum, is a painless, soft, elastic, distinctly-fluctuating tumor upon 
the scalp, and is produced by an extravasation of blood between the 
pericranium and bone, and, for the purpose of more accurate defini- 
tion, is also called cephal^matoma subpericranium. The extravasa- 
tion most probably occurs during the delivery ; for as early as the 
first day of life, when the common caput succedaneum begins to dis- 
appear, a very distinct swelling is noticed, which remains from the 
fourth till the sixth day, at the longest, when a tumor of the size of a 
ripe apple is discovered upon one of the parietal bones. Usually it 
is observed on the right side, and is only exceptionally met with on 
both parietal bones. They never extend over a suture. 

When this tumor has existed for several days, the finger, in travel- 
ling toward it from the normal scalp, encounters a firm bony ring 
which surrounds the base of the tumor. This is a bony exuberance 
which has developed itself between the bone and the periosteum, which 
is elevated by the extravasated blood (PI. II., Fig. 5, No. 6), and de- 
notes the commencement of absorption. Gradually the tumor loses its 
softness, and imparts to the finger a peculiar sensation or noise, due to 
a commencing formation of bone upon the surface of the pericranium 
facing the extravasation. By degrees the tumor decreases in height, 
constantly becomes harder and flatter, and, after three or six months, 
an irregularity or inequality of the bone is only detected by carefully 
feeling with the finger, and the scalp at this time may easily be 
moved over the tumor. Cephalsematoma is a tolerably rare disease, 
and occurs only once or, at the most, twice, in one thousand new-born 
children. 

Etiology. — Its cause, according to Valleix, seems to be the follow- 
ing: In most of the easily-delivered children, an ecchvmosis of the 



60 DISEASES OF CHILDREN. 

pericranium is found, three inches in lengih and two in width, extend- 
ing to both sides of the sagittal suture, more extensive, however, on 
the right parietal bone than on the left. Most probably it is due to 
the circular pressure of the dilated os uteri. In fact, these ecchy- 
moses are most frequently met with on those places where the cepha- 
laematomse generally occur, so that the latter seem to be only a 
higher degree of those small haemorrhages which commonly occur. 

In the frequency of difficult deliveries and the rarity of cephalsema- 
toma, it will certainly be necessary to assume an especial thinness or 
friabihty of the vessels of the cranium, in addition to this mechanical 
circumstance, and the cephalaematoma in hreech deliveries observed by 
I^dgele, SiXter^ and Meissner, show conclusively that the affair is not 
so simple as Valleix supposed, but that still other causes must partici- 
pate here. 

In addition to these peculiar bloody tumors of the bones of the 
head, haemorrhages upon and beneath the Galea aponeurotica likewise 
very rarely occur after difficult dehveries, especially as a result of the 
use of the forceps ; they are very diffuse, never have an osseous ring, 
and are more rapidly absorbed than the genuine cephalaematoma, at- 
tended by a greenish and brownish discoloration of the scalp. PI. II., 
Fig. 6, exhibits a section of such a cephalaematoma subaponeuroticum 
sive spurium. 

Finally, conjointly \vith the true cephalaematoma, but also without 
it, an extravasation of blood is occasionally found upon the internal 
surface of the skull, between the bone and dxira mater (PI. II., Fig. 7). 
Convulsions and paralysis are the usual consequences here of pressure 
on the brain. It is not possible to diagnose positively this meningeal 
apoplexia ; when, however, these symptoms supervene upon cephalae- 
matoma subpericranium, then the complication of cephalaematoma 
meningeum may be assumed with tolerable certainty. This process 
usually terminates in death. 

Besides being liable to be mistaken for C. subaponeuroticum, the 
genuine cephalaematoma may also be confoimded with : 

(1.) Cajnit succedaneum^ the common tumor of the scalp. It is 
an oedema of the scalp, does not fluctuate, and pits on pressure. It 
disappears in the first twelve or twenty-four hours, whereas cephalae- 
matoma is scarcely perceptible at birth, grows from day to day, till, at 
the end of eight days, it has attained its greatest dimensions, and be- 
comes surrounded by a bony ring. The cejDhalEematoma is often hidden 
by the caput succedaneum for the first twenty-four hours. 

(2.) With congenital pi'olajysits of the hrain (hernia cerebri con- 
genita). Rupture of the brain never occurs on the parietal bones, but 
always between the cranial bones, in the sutures and fontanels. It 



DISEASES CONSEQUENT ON DELIVERY. Ql 

bulges out more when the child cries or coughs, and easily induces con- 
vulsions. The scalp covering it is mostly thin and devoid of hair. 

(3.) With vascular tumors. These are very rare in the new-born ; 
and, when they do occur, are very seldom met with upon the scalp. 
They do not fluctuate, have a doughy feel, and no bony ring. The 
integument covering them has a bluish tinge, due to the strongly- 
developed veins beneath. 

Treatment. — The treatment may very readily be divined from the 
delineation which we have given of the course of the evil. If the 
cephalsematoma is quietly left to itself, is not squeezed, the skin cover- 
ing it is not irritated, and no surgical procedures are undertaken, it be- 
comes completely absorbed, as stated above, in from three to six 
months, the children at the same time continue to develop with- 
out any hinderance, suffer no pain when the uneven bone is pressed, 
and, in general, experience no bad effects from the entire process and 
its sequelae. 

Notwithstanding these incontrovertible facts, there are a number 
of methods of treatment which have been invented partly by surgeons 
anxious for an operation, and partly by altogether too meddlesome 
physicians. The tumor has been washed with all possible aromatic 
waters, been smeared with iodine, ammonia, and blue ointments, etc., 
etc. A mild pressure has been exercised upon the tumors by pencil- 
ling them with coUodium, or by a tin plate with which the child's 
cap was lined, caustics have been applied, setons introduced, and, 
lastly, the blood has been evacuated from the tumors by puncturing, 
slitting, or even by dividing them by a crucial incision. 

Compression, cauterization, puncturing, and incisions, only cause 
harm and danger through irritation of the scalp, and exposure to the 
air of the bones denuded of periosteum. In the so-called discussive 
treatment, the most harmless remedies are the best, and I therefore 
use only some indifferent kind of fat, which is daily rubbed, upon the 
tumor. According to FurtKs report, I learn to my satisfaction that, 
for many years back, sixty-nine cases have been treated in the Vienna 
foundling-houses on the purely expectant plan, and with the best 
results. 

T>.— DISEASES OF THE NAVEL. 

After the cord has been divided, the portion remaining adherent 
to the abdomen of the child begins to dry up, and falls off between 
the third and tenth day. The time for the separation of the cord from 
the body is subject to the formation of the funis ; when it is thin, 
it will drop off rapidly ; when thick, or, as the midwives say, fat, it 
requires a longer time for the water contained in the Whartonian 



62 DISEASES OF CHILDREN. 

gelatinous substance to become absorbed or evaporated. As a result 
of tlie customary enveloping of tlie cord in a rag, and of confining it 
by the belly-band, it becomes flattened like a piece of tape, on wliicli 
the arteries and vein are seen as three dark stripes. At the place 
where the Whartonian gelatinous substance joins the abdominal 
walls, the integument, at the shrinking of the umbilical cord, becomes 
contracted into a radiated depression, and, when the cord finally falls 
off, a tolerably firm, dry cicatrix is found to have formed. In some 
instances the integument is found prolonged for some distance upon 
the cord, by which, after the latter has dropped off, a disproportion- 
ately large pad and a deep funnel result, a condition that has been 
denominated " flesh navel," and is delineated on PI. I., Fig, 9, a and b. 

In fat umbilical cords, this process of cicatrization is less ad- 
vanced ; instead of the cicatrix, a red, inflamed, humid, or an actual 
suppurating surface appears, from which various pathological condi- 
tions originate. The desiccation of the cord progresses only in the 
living child ; when the new-born dies, soon after birth, the cord does 
not desiccate^ but quickly begins to rot, and, in medico-legal autopsies, 
this point may serve as an index in determining the time when death 
ensued. 

Treatment of the Normal Navel. — In order to obtain a uniform 
desiccation and dropping off of the umbilical cord, it is necessary to 
protect it from all traction and maltreatment. It should be wrapped 
up in a fine soft piece of cotton or linen rag, and confined to one side 
by the belly-band. In dressing and undressing of infants, as well 
as during bathing them, all handling of the navel-string, that is con- 
stantly becoming stiffer, should be avoided, and the attempt should 
never be made to pull or twist the cord with a view to its speedy 
removal. 

Tlie following pathological processes occur during or after the fall 
of the cord : 

(1.) — Inflammation of the Umbilical Vessels {phlebitis and 
arteritis iimhilicalis). — It sometimes happens fortunately, however, 
but rarely, that the coagulated gelatinous substance which fills 
out the umbilical vessels, beneath the abdominal muscles, becomes 
purulent, decomposed, and produces a sero-purulent discharge from 
the navel. By pressing around it, a few drops of serum may be 
squeezed out at one time. Owing to the pain and inflammation, the 
children are very restless, exercise the abdominal muscles as little 
as possible, and invariably have fever. Soon py»mic inflammations 
of the serous membranes, or erysipelas of the abdominal parietes, be- 
come superadded thereto, and the children perish, at the longest, by 
the end of the third week. When, exceptionally, no purulent absorp- 



DISEASES CONSEQUENT ON DELIVERY. 63 

don occurs, the discharge grows less, and the navel, after several 
weeks, becomes firmly cicatrized. But, as these cases of phlebitis 
are especially observed in lying-in houses where puerperal fever pre- 
vails, it is generally followed by pygemia and death. 

Treatment. — The treatment is very simple ; no crusts are allowed 
to form upon the suppurating surface, hy keeping it constantly cov- 
ered with compresses dipped in warm water, and also by syringing 
the parts with warm water every two or three hours. The main 
indications always are the speedy removal of the child from the 
infected lying-in hospital, and to provide for it a strong, healthy wet- 
nurse, which, of course, can only be achieved in the fewest number 
of women confined in a lying-in asylum. If compelled to feed the 
patients by hand, milk and water, or milk with tea, will serve during 
these processes to prolong life. Diarrhoea must be arrested as quickly 
as possible by muc. gum. arab. | j, with tincture of opium gtt. j, of 
which one or even two teaspoonfuls may be given. 

(2.) — Bleistnoeehcea and Ulceeation of the Navel. — In fat na- 
vels, or in consequence of uncleanliness and maltreatment of the new 
cicatrix, it begins to discharge after the manner of mucous mem- 
branes. This, however, is readily arrested by the use of lead-water, 
compresses, or by touching the surface with lunar caustic. But, when 
this condition has lasted for some time, small excoriations begin to 
form upon the abdomen, the whole surrounding integument becomes 
inflamed, is painful to the touch, and a round ulcer, of the size of a 
penny, forms. In the worst cases, perforation of the ulcer, perito- 
nitis, and death, may follow. 

Treatment. — By the application of tepid-water compresses, and sub- 
sequently touching it with lunar caustic, cicatrization of the navel will 
almost always be attained, if the children in other respects are well 
nourished and suffer from no digestive disturbances ; in the contrary 
case, the pain and suppuration of the ulcerating navel naturally con- 
tribute to hasten the atrophy and exhaustion. 

(3.) Gangrene of the Navel. — In feeble children delivered in 
lying-in houses, where puerperal fever prevails, an umbilical phlebitis, 
or even the just-described ulcerating navel, may become gangre- 
nous^ it becomes converted as it were into a grayish-brown sphacelous 
mass ; the gangrene rapidly encroaches upon the abdominal walls, the 
epidermis becomes loose, may be pulled off, and the cutis found be- 
neath has a gray, bluish color. Bloody serum occasionally exudes in 
tolerable quantities from between the sphacelous mass. In most in- 
stances peritonitis rapidly supervenes, and the faeces may also escape 
through a gangrenous ulcer if agglutination of a portion of the intes- 
liiies with subsequent ulceration has taken place. These patients but 



64 DISEASES OF CHILDREN. 

very rarely recover; in case of recover}"-, the gangrene becomes cir- 
cumscribed, the slough falls off, and a granvdating surface remains be- 
hind. The usual termination is death in from eight to fourteen days. 

In the treatment, unsparing cleanliness and a good vret-nurse are 
the most important agents ; chlorine-water comjoresses, or water con- 
taining tr, myrrh, are very useful for the purpose of eradicating the 
gangrenous odor. Pure coflFee with milk and sugar, or a few tea- 
spoonfuls of Avine, will always prove the most effectual means of 
supporting the extremely depressed state of the health. 

(4.) Ulceration of the Umbilical Stump — [Fungus Umbili- 
calis). — Sometimes after the cord has dropped off, and before it has 
become cicatrized, a pediculated excrescence springs up from the raw 
surface, which may attain to the size of a pea and larger, and, of 
course, hinders the formation of a cicatrix. The adjacent abdominal 
integument becomes puffy, red, and excoriated, and by neglecting 
these symptoms there is great danger of gangrene supervening. If 
excoriations have already formed, they should first be thoroughly 
cleansed, and the umbilical fold should be fvilly opened, so as to en- 
able one to ascertain accurately the cause of the ulceration of the 
stump, for very often it becomes covered by the puffy folds as is rep- 
resented in Fig. 8 on PI. II, If the stump and umbilical folds are 
excoriated, it might be supposed that a wound existed, and this 
erroneous supposition can only be avoided by thoroughly opening and 
carefully examining the fold. The treatment consists in abscission or 
deligation of the stump. Abscission may be performed without any 
assistance ; the umbilical fold is stretched out with the left hand, and 
the pedicle is severed with a Cooper's scissors in the right, after which 
the bleeding surface is touched with a piece of lunar caustic. In the 
deligation both hands have to be employed, and an assistant is there- 
fore required, who is to stretch out the umbilical fold with one hand, 
while with a probe in the other he pushes down the ready-made noose 
as deep as possible. As the ligatm^e is tightened it cuts through the 
stump, and here also a slight hsemorrhage takes place, but which is 
readily controlled by lunar caustic. From what has just been said it 
follows that the abscission of the pedicle is much easier, simpler, and 
just as devoid of danger as the deligation. I presume that, if this pedi- 
culated stump were left to itself, it would desiccate by degrees and die, 
and a spontaneous cure would thus take place. 

(5.) HAEMORRHAGE OF THE Navel. — After the navel-cord has 
fallen off, and before complete cicatrization has taken place, highly 
dangerous bleeding occasionally occurs, which is but seldom possible 
to control. Suddenly and without any cause the belly-band is found 
to be bloody, and, when it is untied, drop after drop of blood is seen 



DISEASES CONSEQUENT ON DELIVERY. 65 

to well up out of tlie umbilical depression. If the blood is gathered 
up in a watch-glass it will take several days before it becomes co- 
agulated, and the coagulum that has finally formed remains loose and 
flocculent. The children continue to bleed and perish in a few days, 
having become extremely angemic, with petechife and ecchymotic 
spots dotting the whole surface of the body, and which at the autopsy 
are also found upon the pleuras and pericardium. This disease, on the 
whole an extremely rare one, for it only occurs once in 10,000 new- 
born children, I have seen but once ; at the autopsy the umbilical 
vein and arteries were found to be completely filled up with thrombi. 
This child died on the eleventh day, and the father informed me that 
he was the son of one who was predisposed to haemorrhage ; that he 
would bleed for days from any slight and ordinary cut, and that at 
one time he lost so much blood, after the extraction of a tooth, that 
he remained pale and feeble for many months thereafter. Heemor- 
rhage of the navel is, therefore, with probability to be regarded as the 
first indication of a heemorrhagic diathesis and blood dyscrasia, and 
that is probably also the reason why these cases of hcemorrhage occur 
so infrequently. 

Treatment. — The ordinary local heemostatic remedies and the very 
much praised liq. ferri sesquichlor. are totally inert here, as also the 
deligation en masse advised by Dubois and Scanzoni, accomj)lished 
by deeplj'' transfixing the navel crosswise with two needles, and 
twisting a ligature over them in the form of a figure of 8, proved in- 
effectual in my case, as the blood continued to flow from the new 
punctures made by the needles. Thomas Hill has cured a case by 
pouring a solution of plaster of Paris upon the freshened wound of the 
navel, and filling up the fissures and cracks originating subsequently 
with new plaster; this method is at any rate devoid of danger, 
and easily carried out, and therefore deserves future trials. The 
treatment recommended by some surgeons, to search for the umbilical 
arteries and vein, and when found to deligate them, is based upon 
the erroneous supposition that the blood comes from these vessels ; 
but the case alluded to proved that the hgemorrhage had no such origin. 
If the theory of a blood cachexia is adhered to, which until now has 
had the greatest probabihty, it will very readily be perceived that all 
operative measures have to be discarded. 

(6.) Rupture of the Navel — {Hernia UmhiUcalis). — By rupture 
of the navel, two conditions are briefly understood, which have scarcely 
any resemblance to each other, namely, congenital and acquired rup- 
ture of the navel (exomphalus, omphalocele congenita, rupture of 
the umbilical cord — hernia umbilicalis, omphalocele acquisita, rupture 
of the umbilical ring). 



QQ DISEASES OF CHILDREN. 

Congenital rupture, or rupture of the umbilical cord, is due to an 
arrest in the development of the abdominal coverings, in the fissure 
of which the rupture makes its appearance. The abdominal plates of 
the embryo, which grow right and left from the primitive lines or 
stripes, are the first rudiments of the abdominal parietes ; they grow 
into the germinal vesicle, approach each other with their borders, and 
by that means enclose a cavity — the future abdominal cavity — in 
which a portion of the germinal vesicle becomes constricted. This 
constricted portion of the germinal vesicle is converted into the intes- 
tinal canal, which communicates by a passage with the portion of the 
vesicle lying outside of the belly (umbilical vesicle). This passage is 
the intestinal navel / the borders of the still incompletely united ab- 
dominal plates svuTOunding it form the memhranoKS navel {Haut- 
nabel). Now, if this constriction, which, up to the seventh or eighth 
week of fetal life, is absent, does not take place properly, the alimen- 
tary canal will develop itself in the open vesicle, will thereby keep it 
permanently open, and the liver is very much disposed to pass into the 
spacious vesicle, into which it is directly urged by the umbilical vein. 

If the portion of the bowel which is normally retained at the base 
of the navel-string does not return into the belly at the proper time, 
and continues to develop itself in the umbOical vesicle, it will finally 
attain a dimension that wUl also prevent its return into the abdominal 
cavity after the delivery, as fruits, which, while unripe, have been in- 
troduced into a bottle, are found impossible to be extracted when 
they have become ripe. 

But, if a part of the liver shares the umbilical opening in con- 
junction Avith the bowel, then the Kver, by its density, will keep the 
ring wade open, and the bowel contained in the vesicle, through its 
increase in size, retiirns again into the abdominal cavity. Those con- 
genital umbilical ruptures, in which a portion of the Hver does not in- 
terv^ene, can never be reduced, the knuckle of intestines becomes gan- 
grenous immediately after birth, after the cord has fallen off, followed 
by peritonitis and death. Congenital ruptures which contain a section 
of the liver, possibly, are capable of undergoing a spontaneous cure. 
The peritoneal coat of the liver becomes covered with granulations, 
the large opening gradually contracts, and a firm cicatrix forms. 
Debout has seen a case cured in this manner. The treatment is very 
simple : the granulating surface is covered with a piece of lint smeared 
with cerate, and the child is nomrished as well as possible. 

The acquired rupture^ rupture of the umbilical ring, occurs several 
weeks or months after delivery, after the cicatrix of the navel has 
formed at the right time and in a proper manner, and is principally ob- 
served in rather lean children, who suffer much from flatulence and 



DISEASES CONSEQUENT ON DELIVERY. 67 

cry continuously. The umbilical ring is stretched a little, and the 
abdominal pressure forces a piece of the small intestines through it, 
pushing the peritonseum and the distensible umbilical cicatrix in ad- 
vance, so that a protuberance presents itself instead of the usual de- 
pression, which may attain to the size of a cherry or even of a 
small apple. A white, glistening spot is found in the centre of the 
navel, which corresponds to the place where the three umbilical vessels 
have become united after the cord has fallen off, and has been called 
the vascular navel {GefCiss-nahel). It is less distensible than the 
membranous navel, and therefore is not always found upon the sum- 
mit of the rupture, but either laterally or downward. The rupture 
usually contains a small knuckle of the small intestines, which but 
very rarely pushes a portion of the omentum before itself. The re- 
duction is, in all cases, accomplished without any difficulty, after 
which the size of the ring may be ascertained with the point of the 
finger. By the use of a proper truss, the umbilical ring does not simply 
decrease in size, but becomes converted, as I have often observed, into 
a diagonal fissure, the borders of which gradually approach each other. 
I have never yet met with any incarcerations of the intestines here. 

The treatment of this rupture, which mostly also heals spontaneously, 
consists in the adaptation of a stopple made of charpie, cotton-cloth, or 
cork- wood, but which should be a little larger than the umbilical ring, 
and securing it by pieces of adhesive plaster six by eight inches square, 
and by a belly-band, the hernia having been pre\aously reduced. When 
the parents of the child have once been taught how to apply this appa- 
ratus, it may then be bathed daily and the compress is applied again 
after each bath. I cannot agree with the opinion of some authors, 
that the rupture should be supjoorted by long strips of adhesive plas- 
ter running around and across the whole body, as the abdominal respi- 
rations are thereby very much impeded ; furthermore, there is no plaster 
that will not erode the skin after a while, and it is much more difficult 
to instruct the parents how to renew this apparatus than the one 
recommended above ; besides which, in the other case, the bathing 
has to be neglected for a long time, to the great detriment of the child. 
By this simple method, if assiduously applied, each and every umbiHcal 
ring, even though it is ever so much dilated, may be brought to a clos- 
ure in from three to six months, if the child in other respects thrives 
well. 

y:.—tiusmus and tetanus of the new-bobn. 

Symptoms. — (rpitJ/iof, to gnash ; and rt'-avor, rigid convulsions.) Be- 
tween the first and fifth day after the cord has dropped off, never before 
nor later, children are sometimes attacked by trismus. Certain pre- 



68 DISEASES OF CHILDREN. 

monitory signs usually precede the attack, such as restlessness, crying, 
a peculiar trembling of the lower jaw, starting up from sleep, and 
avidity for the breast, which, however, the child instantly forsakes again. 
After these premonitions have lasted several hours, at the most a 
day, the child is found to be unable to open the mouth. The masti 
cators are felt to be hard and tense, but the integument over them, in 
contrast with scleroma, is movable. The countenance loses the ex- 
pressionless appearance peculiar to the new-born, the mouth becomes 
pointed, the compressed lips are corrugated by striated wrinkles, the 
forehead and cheeks become wrinkled, the eyes, surrotmded by a bluish 
ring, are firmly closed, the head is strongly retracted, the nape is 
stiff, the skin is turgid and reddened. The child is not able to 
swallow ; even when the jaws with difficulty have been opened and 
some fluid has been poured into the mouth, the nutriment invariably 
flows out again in a very short time. This condition, at first, has some 
intermissions ; the spasms remit for hours at a time, so that a re- 
covery may be supjDosed ; they, however, invariably return, constant- 
ly grow more protracted, and mostly persist till death occurs ; 
only occasionally do the contracted muscles become relaxed before 
the close of life. In the severest form of the disease, the muscles 
of the entire body become so intensely rigid, that the child may be 
raised up like a stick of wood. Death takes place in from one to eight 
days, by suffocation or from exhaustion. The child is either choked 
in consequence of the closure of the glottis during a convulsive parox- 
ysm, or in consequence of the generally rigid, totally incapacitated 
inspiratory muscles. In the second case, in death from exhaustion, it 
is the frequent occurrence of the convulsions which produces a rapid 
sinking of the strength of the system. In protracted cases, the depri- 
vation of sleep and sustenance brings about a final dissolution. 

Etiology. — In very few internal diseases can the cause be pointed 
out with so much certainty as in trismus neonatorum. A disease that 
makes its appearance only between the first and fifth day after the 
cord has fallen off, must certainly have some connection with the cica- 
trization of the navel. It is also very natural, in such a rapid con- 
traction of the tissues as takes place here, for a nerve now and then 
to become compressed, or be dragged, and thus produce all the reflex 
contractions, as we see them induced in traumatic tetanus by a foreign 
body. This will occur all the more readily if the umbilical cord was 
thick, treated roughly, and, as a result of which, ulcerations supervened. 
In most autopsies of children dying from trismus, marked morbid alter- 
ations in the umbilical arteries and vein are found, such as dilatation, 
redness, softening, ulceration of the vascular coats, pus and serura 
within and in contiguity \vith these vessels. 



DISEASES CONSEQUENT ON DELIVERY. 69 

In Germany, the disease occurs only in the sporadic form ; I have 
been unable to determine whether it might be more frequent at certain 
times or under certain changes of the weather. I have seen it at all 
times of the year, and under all states of the barometer, in cool and 
hot, moist and dry weather. In the Dublin lying-in houses, and in 
Mailand, trismus has been observed in an epidemic form ; it is endemic 
in Trieste, Spain, Minorca, in the West Indies, and Cayenne. Half 
of the children born in some of the colonies of Guiana are said to 
perish from tetanus. It not only occurs endemically in the southern, 
but also in the high northern latitudes, in Iceland, for instance, where 
the natives designate it by the name of " lock-jaw," " chinclose." And 
Mackenzie states that it rages so violently among the children born 
on Westman Ever — islands on the southern coast of Iceland — that 
the small population is only sustained by immigration. 

Aside from the alterations in the umbilical vessels already men- 
tioned, pathological anatomy furnishes no characteristic lesions. The 
plethoric condition of the spinal cord, and the bloody effusions occa- 
sionally met with in the spinal canal, are, no doubt, secondary pro- 
cesses. The bodies retain their wood-like rigidity for some time after 
death, and even in the warm seasons feel as cold as ice. 

The prognosis is extremely unfavorable. Golis and Heim^ in all 
their extensive practice, have not seen one case recover. Hufeland 
puts the ratio of mortality as = .50 to 1. All of my patients, at least 
ten or twelve, died under the best methods of treatment recommended. 

Treatment. — Since, according to my experience, and that of the 
most extensively employed children's physicians, the once-developed 
trismus neonatorum invariably leads to death, it is therefore doubly 
important to pay the utmost attention to the prophylactic treatment ; 
for it will not be easy to find a case in which, by strict investigation, 
some neglect in the care of the umbilical cord will not be discovered. 
Of course, where the affection prevails so endemically that a great 
number of the new-born are carried off by it, FranJc's advice is to be 
followed, according to which, the pregnant women must leave the 
dangerous region and not return until complete cicatrization of the 
navel has taken place. 

A cautious management of the umbilical cord, such as has already 
been described on page 49, and a cleanly, forbearing treatment of the 
still incompletely-formed cicatrix of the navel, to which principally 
a uniform temperature of G6 to 68° F., pure air, and healthy mother's 
milk belong, are therefore to be strictly insisted upon. 

Since it has never yet been my good fortune to cure a child of 
trismus, I am therefore unable to suggest any remedy for the fully- 
developed disease, and must content myself by enumerating the vari- 
G 



70 DISEASES OF CHILDREN. 

ous methods of treatment that have been employed and generally 
acknowledged as useless : (1.) The antij^hlogistic treatment, especially 
abstraction of blood ; (2.) Antispasmodics and narcotics ; (3.) Dia- 
phoretics and counter-irritants; and (4.) The evacuating method. 
Each of these methods of treatment has its advocates, and each has 
its contemners. 

Of all the remedies, the narcotics are the most promising. In one 
case I gave tr. opii, one drop every hour ; in another, one drop every 
two hours ; in another, I used chloroform every two hours. In this 
child, the rigidity passed off during each narcotism, but returned in 
from half to one hour afterward. On the next day the symptoms 
were the same ; and, as I was about to narcotize it for the seventh 
time, I found it was dead. The most rational treatment seems to be, 
not to allov/ the child to perish by inanition ; which is accomplished 
by injecting, twice daily, milk or beef-tea, with yolk of eggs, into 
the stomach by the aid of a gum-elastic catheter, which is easily 
introduced through the oesophagus ; and to cauterize the spot that 
formed the starting-point for the trismus, the cicatrix of the navel, 
with the ferrum candens (actual cautery), a treatment which I intend 
to try in the next case that may present itself to me. 

[Dr. Alois Monti, of the St. Ann's Child's Hospital at Vienna, 
reports in the Jahrh. far IvhiderheilJcunde, 1869, three cases out of 
five cured by calabar bean. He prefers subcutaneous injections, as 
he thinks the internal use uncertain. He repeats these injections 
every ten or fifteen minutes until the spasms cease ; then intermits 
them even for several hours until the convulsions return. For new- 
born children he uses one-tenth of a grain of the extract per dose, 
and goes up to one-third, one-half, or a whole grain a day. Older 
children can commence with one-third of a grain at a dose. For in- 
ternal use, from one to four grains a day may be given. 

Reasoning from the facts that chloral hydrate has been employed 
with success in tetanus of the adult, both idiopathic and traumatic, 
and that the cause of trismus neonatorum is believed to be an irrita- 
tion of the sentient extremities of the cutaneous nerves exposed in 
the unhealed surface left by the decadence of the cord, we venture to 
suggest the future use of this powerful sedative in cases of this hith- 
erto almost irremediable disease,] 

Y— SCLEROMA (/rem o--cXwof, ^'ard). INDUE ATIO TEL.^. CELLULOSE, 
ZELLGEWEBSVERHARTUNG (INDURATION OF THE CELLULAR 
TISSUES). 

Scleroma, by some also called oedema neonatorum, or oedema 
compactum, consists in an induration of some parts of the cutis, 
which, in this manner, occurs only in the first weeks of infantile life. 



DISEASES CONSEQUENT ON DELIVERY. ^1 

Sjnnptoms. — The infiltration of the integument begins on the lower 
extremities, the redness of which increases while the temperature at 
the same time decreases. At first the calves of the legs swell up, and 
become perfectly stiff and hard ; the swelling next attacks the feet, 
b}^ which the soles of the feet become peculiarly convex ; it then ex- 
tends upward over the knees, upon the thighs, to the genitals, the 
pubis, nates, and navel ; the thorax in a most remarkable manner is 
always spared ; on the other hand, the upper extremities and the face, 
particularly the lips and cheeks, which then assume a peculiar glossy 
appearance, are very generally implicated in scleroma. The dark- 
red color of the affected places, that is seen at the invasion M the dis- 
ease, very soon fades, and gives way to a yellowish ; the skin be- 
comes dry, and the epidermis, which otherwise is always cast off, 
does not attain to a desquamation here. In the most intense form 
of scleroma, the child lies intensely swollen, cold, and stiff, like a 
frozen corpse. The hard, glistening cheek, the puffed-up oedema- 
tous eyelids, which are scarcely able to open themselves, disfigure 
the face so much as to make it entirely unrecognizable. At the in- 
vasion of the disease, the affected parts of the skin are still movable, 
and will pit on pressure with the finger ; later neither is possible. 
The low temperature is characteristic of the disease, the thermome- 
ter, in the mouth or rectum, marking only 73° F. Artificial warmth, 
hot baths, bottles filled with hot water, etc., will temporarily raise 
the temperature of the cold extremities, but not more than that of 
any other inanimate object. 

All the physiological functions are here either suppressed, or but 
feebly developed. The respiration is superficial and slow, the voice 
weak and whimpering ; the cry is never loud nor continuous. The 
child sucks only for a few minutes, and extracts but a small quan- 
tity of milk from the breasts. The meconium is not evacuated for 
some time, the secretion of the urine is very much diminished. The 
pulse is always very small and slow ; according to Valleix, it ranges 
from sixty to seventy-two beats per minute ; later, when the scle- 
roma is far advanced, it can no more be felt in the extremities, on 
account of the induration of the integument. The action of the heart 
is extraordinarily feeble ; the second sound is scarcely audible at all. 
The sensibility of the affected parts of the skin is almost wholly 
gone, which can be proved by pricking them with a pin. The fur- 
ther the indurated oedema advances, all the more profound becomes 
the lethargy, all the slower the respiration, all the more perceptible 
the coldness. Finally, a bloody serum flows out of the mouth and 
nose, and death ensues without any convulsions, simply by the res- 
pirations becoming slower and slower, and then ceasing altogether. 



72 ■ DISEASES OF CHILDREN. 

In the rare eases which merge into recovery, deeper and easier 
respirations are at first observed, the action of the heart becomes 
stronger and quicker, the appetite increases, and lastly a diminution 
of the oedema of the indurated jDarts takes place. According to Val- 
leix, the eyelids and upper arms are the first to become thin and 
flaccid, then the buttocks and the hypogastrium, later the hands ; 
the legs and feet remain cedematous for some time after the other 
parts have become normal. So long as the feet are still swollen, the 
subjects cannot be declared out of danger ; they sometimes become 
drowsy, drink less, and die in two or three weeks. 

The affected parts retain the violet-red color for some time after 
the oedema has totally disappeared ; the skin is weak, soft, and cor- 
rugated, and does not regain its normal condition for some time. 

Lobular pneumonia is the most frequent complication ; Valleix 
observed it five times in twenty-five cases. Intestinal catarrh is very 
rarely present, most probably owing to the difficult introduction of 
sustenance. Yellow discolorations of the new-born naturally fre- 
quently occur, but true icterus with yellow sclerotics, urine contain- 
ing coloring matter of the bile, and gray fasces, are, on the whole, 
very rare in children, and have no special reference to scleroma. 

Post-mortem Appearances. — After death the parts affected by 
scleroma rapidly become blue, and retain their hardness and rigid- 
ity ; the rest of the skin, especially of the trunk, is normal, yellow- 
ish-white. The infiltration is most marked on the side on which the 
body has been placed, as a result of the fluids gravitating toward 
the most depending parts. On incising the affected integument, 
black, semi-fluid blood flows out, but from the subcutaneous cellu- 
lar tissue, which is so intensely cedematous, and which has produced 
that enormous enlargement of the extremities, a large quantity of 
yellow or sanguinolent liquid exudes, which neither chemically nor 
morphologically differs from the ordinary dropsical serum. After 
this fluid has escaped, the indurated parts become soft and flaccid 
again. The connective tissue over the aponeurosis is converted into 
a gelatinous mass of two to four lines in thickness ; beneath the apo- 
neurosis, in the intermuscular structure, no oedema is ever found. 
The solidification of the adipose tissues, which occurs when the 
corpse has been exposed to cold, should not be confounded with this 
condition. In that case, too, the extremities feel hard and stiff, but 
they are not swollen, and are not so blue, and, on incising, the sub- 
cutaneous cellular tissue is found normal, dry, and without any gela- 
tiniform infiltration. 

In scleroma, then, we have essentially to deal with an acute 
oedema of the skin, the causation of which is to be sought in general 
circumstances. The rest of the organs are not constantly changed ; 



DISEASES CONSEQUENT ON DELIVERY. Y3 

most frequently serous effusions into the peritoneal and pleural sacs 
are found, and lobular pneumonia occasionally supervenes. The 
fetal circulatory passages are sometimes closed, sometimes again 
still open, as is very frequently the case in infants who die in the 
first days of life ; scleroma, therefore, cannot be regarded as having 
any special connection with greater alterations of the circulation. 

Etiology. — Scleroma attacks by preference premature children. 
On the whole, it is much more easy to decide what does not produce 
scleroma, than what does produce it. It does not originate through 
the fetal passages remaining open, nor from lobular pneumonia. It 
is especially to be borne in mind that the retardations of the pulse 
and of the respirations, with the exception of those cases that are 
complicated with pneumonia, are constant phenomena. Most prob- 
ably, therefore, it is the lack of innervation of the cardiac muscle, 
which does not contract often enough, and thus produces the cold- 
ness and peripheral transudation. The disease is decidedly more 
frequent in winter than in summer. 

Treatment. — Valleix has seen two children recover, in each of 
which two leeches were applied behind each ear. Other children 
died under the same treatment. The most important part of the 
treatment seems to be to keep up constantly a high temperature of 
the body, which is accomplished by suiTounding it with bottles filled 
with hot water, warm cloths, etc. It is also rational to accelerate 
the contractions of the heart by the administration of alcoholics ; 
on the whole, however, it cannot be denied that all these agents, as 
a rule, prove ineffectual, and only in exceptional cases, in slightly- 
diffused scleroma, do they accomplish a favorable result. 

Qc.—melj<:na neonatorum. 

Between the first and third days of infantile life, gastric and in- 
testinal haemorrhage occasionally occurs. Vomiting of blood is less 
frequently observed than bloody, discolored faeces. The bloody 
stools are almost always very copious, and recur at short intervals. 
The blood is sometimes fluid, and then again coagulated into large 
lumps. In this affection the patient sinks very rapidly into a state 
of collapse, the lips become blue, the skin cold, the pulse is barely 
perceptible, and symptoms of acute cerebral anamia sujDervene, 
Usually, the haemorrhage runs its course in twenty-four hours ; still, 
it may also last three to five days. The stools retain a dark color 
for many days after the bleeding has stopped. According to JRilliet, 
half of the children attacked by this disease recover. 

At the autopsy large quantities of fluid or coagulated blood are 
found in the stomach and intestines, and the highest degree of anaemia 
in the other organs. The fetal circulatory passages are open ; but 



74 DISEASES OF CHILDREX. 

this, after all, is observed in many new-boi-n who did not die from 
melsena. The tm*gescence of the mesenteric arteries and their sys- 
tems of capillaries, seen even in the physiological state and produced 
by the sudden closure of the umbilical arteries, so important in the 
foetus, and which arise directly from the hypogastric arteries, may be 
looked upon as a cause of this disease. An esj^ecial thinness of the 
walls, or friability of the affected system of vessels, must certainly 
play a part here ; because, otherwise, this in reality very rare form 
of haemorrhage would have to occur much more fi'equently. The clos- 
ure of the ductus venosus Arantii, and especially that of the branch 
of the umbilical vein opening into the portal vein, deserves more fre- 
quent and stricter investigation to explain this haemorrhage. 

Besides becoming bloody from intestinal haemorrhage, the faeces 
may also assume that character through blood having gained an en- 
trance into the mouth of the child, and then been swallowed by it. 
This may happen in all operations on the lips and tongue, in epistaxis, 
the result of a blow upon the nose, or of that organ coming violently 
in contact with a hard substance, from the matei'nal blood having 
been swallowed during delivery ; and, lastly, the new-born may suck 
in some blood from the breasts of the mother when any sores exist 
around the nipples, or when a strong child endeavors to suck for a 
longtime frommilkless breasts. All these admixtures of blood are very 
rare ; the blood in these cases is not found in large quantities, and 
usually is not ejected by the intestines, but thrown up. Nor do the 
infants sink into a state of collapse, as in actual intestinal haemorrhage. 
Treatment. — The only case of intestinal haemorrhage which until 
now I have had an opportunity to treat, occurred in an infant thirty- 
six hours after delivery. In the course of twenty-four hours ten diapers 
were soiled by the discharge of blood-coagula, which were of the size 
of a hazel-nut. The strong, robust child quickly turned to a waxy 
paleness, the extremities became cold, and the pulse was scarcely to 
be felt. I caused the temperature of the room to be raised to 72^° F., 
laid three jugs filled with hot sand around the child, and ordered it to 
drink at the breast of the mother every hour. As in the course of the 
next twelve hours no remission ensued in the bleeding, I gave him — 
I^. Liq. ferri sesquichlorat., 3j. 
Aq. distillat., 

Aq. cinnamon, aa, 3 ss. 

Syr. simple, 3 ss. 

Of which, in twelve hours, the child consumed about the half, and then 
discharged no more blood. I could not prevail upon myself to try the 
treatment with ice-cold milk, and cold applications to the abdomen, 
proposed by Rilliet, on account of the reduction of the temperature of 
the surface of the body that must necessarily result therefrom ; on the 



DISEASES CONSEQUENT ON DELIVERY. ^5 

contrary, I consider it more rational, in this intestinal haemorrhage of 
the new-born, to induce as strong a turgescence as possible toward the 
integument, which is best accomplished by a high temperature. The 
child rallied in a few days after the bloody stools stopped, and from 
that time on has jDrospered excellently well. 

'E..— ICTERUS NEONATORUM {from Urepoi, Jaundice). 

In addition to the physiological yellow discoloration of the skin 
mentioned on page 6, to which, in fact, most of the alterations of the 
color of the skin regarded as icterus belong, there is yet a condition in 
which the coloring matter of the bile is actually retained in the blood, 
and in many instances it is of a very serious nature. Here the sclero- 
tica is yellow, the pus of the ophthalmo-blennorrhoea which occasionally 
supervenes turns to an orange color, and the urine dyes the diapers 
dark yellow. The faeces, however, never become as gray as in the 
adult, but retain a light-yellow or greenish tint. At the autopsy the 
serous membranes, the muscles, bones, etc., are found infiltrated with 
the coloring-matter of the bile, just as is seen in adult icteritics. Most 
of the icteritic children are feverish and suffer from a still uncicatrized 
and ulcerating navel, with which the icterus neonatorum stands in the 
closest connection. In those cases which terminate fatally, usually 
phlebitis of the umbilical, sometimes also of the portal vein, and small 
abscesses in the parenchj^ma of the liver, are found. True icterus 
neonatorum is therefore to be regarded as a local condition or com- 
plication of phlebitis umbilicalis ; it is not, however, possible to main- 
tain that a duodenal catarrh or a mechanical occlusion of the bihary 
ducts may not also now and then cause an icterus. In fact, all the 
icterus of the new-born which terminates favorably belongs to this 
category. Its usual causation, according to JFrei'ichs, is to be sought 
in a diminished tension of the capillaries of the hepatic parenchyma, 
which ensues at the cessation of the afflux of blood on the part of 
the umbilical vein, and causes an augmented transposition of bile into 
the blood. 

As regards the course of the disease, every thing that has been 
said of phlebitis umbilicalis, on page 59, is applicable to the cases of 
the first category ; the subjects, at the most, linger till the fourteenth 
day, become atrophied very rapidly, and mostly perish under a pro- 
fuse diarrhoea. The latter kind, the simple icterus, lasts from eight 
to fourteen days. The yellow color never becomes intense, and 
during the whole course the general condition is barely perceptibly 
disturbed. 

Treatment — The treatment of the pernicious icterus is a mosi 



76 DISEASES OF CHILDREN. 

unsatisfactory one. So far as I am aware, there is not one case of 
recovery to be found in the whole medical literature. All the more 
pleasing, on the other hand, is that of the yellow discoloration of the 
skin, falsely denominated icterus, in prematurely-born children, or 
after difficult deliveries. It invariably disappears spontaneously in 
the course of a few days, and nothing more is necessary than to 
pay attention to the digestion of the child. New-born children 
very rarely suffer from actual constipation ; and, where that is the 
case, the universally beloved syrup of rhubarb will also be capable 
of removing the difficulty. 

I.— CONJUNCTIVITIS BLENNORREOICA NEONATORUM. 

By blennorrhoic inflammation of the conjunctiva (from (3Xtvvog, 
mucus, pus), we understand an inflammation that runs its course, 
not only with a profuse suppuration on the free upper surface of the 
conjunctiva, but also with an effusion of plastic exudation into the 
parenchyma thereof. The secreted pus is contagious, and is poured 
out from the whole upper surface of the conjunctiva. The contagious, 
profusely-secreted pus and the uniform and simultaneous implication 
of the papillary bodies characterize this disease from all others. 

According to the severity of the affection, we distinguish two 
kinds of blennorrhoea as described by Arlt. 

First Kind. — Cases which, immediately from the beginning, are 
inclined to run a very rapid course, and display the tendency to 
attain the highest degree. 

In the first grade of this form the palpebral conjunctiva is relaxed, 
uniformly red, and secretes a tolerable quantity of pus ; all these 
symptoms are present in an acute form. Often the simply purulent 
secretion ceases suddenly and makes place for a thin serous dis- 
charge, in which flakes and fibres swim about, frequently adhering 
with tolerable firmness to the conjunctiva. A marked degree of 
swelling, an acute oedema of the lids, takes place here. Usually this 
condition lasts so short a time (from twelve to twenty-four hours), 
that the physician but very rarely has an opportunity to see it. 

In the second grade of this form the palpebral conjunctiva is 
dark red and very much swollen, so that the inner canthus is no 
longer sharply defined, and the absorption of the tears is j^revented 
by the constriction of the puncta? lachrymalis. The ocular conjunc- 
tiva, too, is already decidedly infiltrated and injected, the discharge 
is mostly like thin broth, seldom thick or purulent, and excoriates 
the adjacent integument. The oedema of the lids is so intense, that 
it is extremely difficult and painful to open the palpebral fissure. 

In the third grade, finally, all the phenomena of the second are 



DISEASES CONSEQUENT ON DELIVERY. 77 

present, only in a more aggravated form, and, in addition, an intensi- 
fied oedema of the conjunctiva bulbi supervenes. The swelling of the 
integument of the lids mounts upward over the supraorbital ridge, 
and downward extends to below the malar bone, and is uniform in 
degree from the outer to the inner angle of the eye, because, in 
reality, it is only a secondary affection of the uniformly-inflamed 
conjunctiva. The secretion is extraordinarily profuse, flows almost 
unceasingly down over the cheeks, sometimes is thin, then again 
thick, watery, or purulent, sometimes brownish, colored by an admix- 
ture of blood. The conjunctiva bulbi is either uniformly infiltrated, 
and surrounds the deeper-lying cornea like a red circular rampart or 
crown, or, in rarer instances, swells up irregularly in the form of weak, 
vesicular exuberations. 

Second JKind. — Cases which, from the very beginning, have a 
more chronic course, and are unattended by any profuse blennorrhoic 
discharge. The latter increases only after several days ; the morbid 
changes upon the entire upper surface of the conjunctivae, however, 
are marked ; granulations and minute warts form, which, in the pal- 
pebral sinuses, unite to form cock's-comb-like excrescences. 

In the^rs^ grade of tliis second form the secretion is very slight; 
the red color, and the uneven state of the conjunctiva, combined 
with some intolerance of light, are its only characteristic symptoms. 
This condition may last several days without the morbid changes be 
coming intensified. 

In the second grade the affection of the conjunctiva palpebrarum 
extends as follows : So far as the papillary bodies reach, on the lower 
about half a line, on the upper nearly one line beyond the orbital 
border of the tarsus, the highly-red conjunctival membrane is seen 
to be closely studded with compressed, uniformly-projecting, equal- 
sized minute warts. At first, these warts bleed at almost every 
touch, but when they have existed for some time — they often last, 
when not treated, for months — they become pale on the upper surface, 
flattened from compression by the eye-bulb, and bleed less easily. 
Tlie strongest tendency to extuberate is always seen upon the con- 
junctiva toward the orbital border, where high, cock's-comb-like granu- 
lations form. 

Here the tumefaction and redness of the lids are but slight, and 
disappear sooner than the affection of the conjunctiva. 

This form of blennorrhoea seldom attains to the third degree; 
only then, as a rule, when, during the disease, still further injurious 
influences come to bear upon the eye. The anatomo-pathological 
characters, on the whole, are the same as those of the third degree oi 
the acute ^rs^ kind. 



78 DISEASES OF CHILDREN. 

Course. — It does not always happen that a blennorrhoea runs 
through all the three degrees ; it often stops at the second, sometimes 
even at the first. Nor is it necessary for both eyes to be implicated ; 
usuallj', however, the pus of the eye first attacked infects the other, 
on account of which the closure of the still sound eye, more minutely 
to be described further on, is of the utmost importance. If an actual 
transportation of the blennorrhoic pus has taken place, as is most fre- 
quently the case in new-born children, the process then runs through 
the first and second grades so rapidly, that the physician, who is called 
in only twenty-four hours afterward, finds the third grade already fully 
develoj^ed, and the eyes, even at this juncture, may already be hope- 
lessly ruined through extensive destruction of the comeae. 

When the affection stojDS at the first stage, it will terminate 
slowly and spontaneously, and without any serious results. Through 
external injuries, however, it may become aggravated to a higher 
degree. 

The second grade is almost unexceptionally caused by contact 
\^dth infecting pus. Here much less tendency to a spontaneous cure 
can be expected, as the extuberations of the papillae and the preced- 
ing suppuration thereof are liable to remain, if not treated, for many 
months. In this chronic com'se the lids become markedly hypertro- 
phied and enlarged ; they never, however, become shortened inwardly ; 
notwithstanding the subsequent cicatrization of the conjunctiva, an 
ectropium of the upper and lower eyelids oftener originates therefrom. 
In other cases, an abbre\aation of the palpebral fissure (blepharophi- 
mosis) may form, as a result of the excoriations. In the second grade 
the cornea is but little endangered ; small and superficial corneal ul- 
cerations, generally, are only met with.* 

The third degree, which may develop itself at any time from the 
first and second, but which may also apjDear very acute without any 
inflammation preceding it, is always an extremely dangerous con- 
dition. 

The Cornea^ as a rule, becomes involved. — At the first examina- 
tion the cornea may have been found to be perfectly clean, transparent, 
and glistening, but, if reexamined a few hours after, it may already 
be softened, purulently infiltrated, and in a great measure destroyed. 
What aggravates the calamity is that this process invariably occurs 
in the centre, just opposite the pupil ; while the periphery of the cor- 
nea, with the centre remaining undestroyed, but very rarely suffers a 
solution of continuity. There is a very remarkable circumstance con- 
nected with these ulcers of the cornea, and that is, that no suppura- 
tion ever takes place between the corneal layers, no unguis forms. 
They have an extraordinarily great tendency to perforate, the iris then 

* See also blepharitis, page 584. 



DISEASES CONSEQUENT ON DELIVERY. 79 

drops forward, and is quickly covered with a grayish exudation, from 
which staphyloma subsequently becomes developed. If the prolapsed 
iris and the exudation covering it are not capable of closing the per- 
foration, phthisis bulbi will take place. In general, the rule may hold 
good, that the later the aifection of the cornea appeared, after the 
blennorrhoea has passed beyond the highest stage of severity, the 
less of a destructive tendency will it display. If ulcerations form, not- 
withstanding the blennorrhoea having existed for some time, say two or 
three weeks, they will, it is true, increase in size much more slowly ; but 
nevertheless often give rise to circumscribed corneal perforations, and 
their effects, prolapsus of the iris, opaque cicatrices, anterior synechia, 
distortion of the pupil, central capsular cataract, staphyloma, etc. In 
this third and highest grade, children usually have a hot skin and fever, 
in consequence of pain and sleeplessness. 

Causes. — Those cases which are met with in private practice must 
be separately regarded from those occurring in lying-in and found- 
ling-houses. The extremely frequent occm-rence of blennorrhoea in 
the first six to eight days of life cannot possibly be attributed to 
general causes alone — glaring light, cold, foul air, uncleanly treatment 
of the eyes, etc. — for these agents, in some measure, still remain in 
force for some weeks thereafter ; whereas the invasion of a blennor- 
rhoea after the eighth day of life, in private practice, is of the greatest 
rarity. 

Hence, an infection through blennorrhoic vaginal mucus, during the 
passage of the head of the child through the maternal passages, is gen- 
erally assumed, by which it is not necessary for syphilis to be present 
and participate. The infecting conditions are then the same as those 
of a gonorrhoea that has originated after an impure connection. Not 
every fluor albus, through coitus, produces a gonorrhoea, and still less 
frequently a blennorrhoea of the conjunctiva during the delivery. 
"Were the latter the case, most of the new-born would suffer from the 
disease under consideration, for almost all women, during the last weeks 
of gestation, have an augmented vaginal secretion, a higher degree of 
which represents a vaginal blennorrhoea. Moreover, the children are 
well protected against infection during delivery by the eyelids being 
firmly closed, and by a proper coating of vernix caseosa, by which the 
rare induction of conjunctival blennorrhoea in comparison with vaginal 
blennorrhoea of the mother may be explained. That this manner of 
infection during the ]:)rogress of the child through the maternal pas- 
sages is not a very intense one, follows from this, that new-born male 
children, in the first Aveeks of life, never acquire a virethral gonoiThoea, 
nor the female a vaginal blennorrhoea. Be that as it may, this much 
is irrefutable, that at least from eighty to ninety per cent, of all con 



80 DISEASES OF CHILDREN. 

junctival blennorrhceas occur in tlie new-born, and that in every in- 
stance the act of the delivery, 'per se, may be regarded as the most im- 
portant etiological agent. 

Where many children are congregated together, in foundling and 
lying-in houses, blennorrhoea also occurs in an epidemic form, especially 
in those l}ang-in houses where puerperal fever prevails. Here it is espe- 
cially difficult to determine in which manner the transportation of the 
pus takes place, since it is known that sponges, towels, diapers, and 
the hands of nurses, when soiled with blennorrhoic pus, are capable 
of conveying the poison to healthy eyes ; the opportunities of infec- 
tion occur in such varied and manifold forms, that it is really unneces- 
sary to resort to the air, light, etc., for an explanation. 

The prognosis depends entirely ujDon the state of the cornea. The 
granulations and the exuberations may look ever so frightful, the pu- 
rulent secretion may be ever so profuse, still all these may pass away 
without leaving any traces behind them ; the morbid alterations of 
the cornea, however, leave their effects for life. The earher the 
cornea becomes implicated, all the greater is the danger of a total de- 
struction. Primary or secondary s^qohilitic vaginal blennorrhoea, as a 
rule, jDroduces such intense corneal participation. The oedema of the 
lids, as a rule, stands in exact relation to the danger of the destruction 
and loss of the eye. 

Treatment. — The task of testing and criticising the various methods 
of treatment recommended by some and denounced by others is ren- 
dered difficult, by the fact that a number of violent hlennorrhoecB 
disappear spontaneously icithout medication and without scrupidous 
cleanliness, and leave behind than no morbid alterations of the 
cornea. 

In Munich, Avhere great negligence prevails among the lower 
classes in regard to the rearing and prosperity of the new-born, it of- 
ten happens that mothers bring to the physician their three or four 
weeks' old children with severe blennorrhoea, for some other ailment, 
and, upon closer inquiry in regard to the affection of the eye, very 
naively remark, " The jaundice attacked its eyes in the very first few 
days ; it is much better now ; at first, however, the eyes were very much 
swollen ; matter and bloody water constantly used to run down over 
the cheeks." If such untreated eyes are examined, the cornea will 
very frequently be found perfectly clean and intact. A recovery has 
taken place without any treatment. In other cases, it is true, both 
bulbs, to the great mortification of the parents, are found completely 
destroyed. These facts must be candidly premised and kept in view 
in estimating the value of the methods of treatment now about to be 
described. 



DISEASES CONSEQUENT ON DELIVERY. §1 

As a prophylactic against transportation of the blennorrhoea from 
the affected to tlie still normal eye, a protective bandaging is espe- 
cially to be recommended. For this purpose the sound eye is covered 
with a light pad of dry charpie, which is secured by a few strips of ad- 
hesive plaster. This pad and plaster should be removed twice a day 
and the eye carefully examined. If the blennorrhoea has attacked this 
eye notwithstanding, then this bandaging has completely failed in its 
object, and must be wholly abandoned in order to facilitate the escape 
of the pus. 

The most important part of the whole treatment consists in a 
thorough cleansing of the eye. In hospitals and lying-in houses where 
the children are constantly under the care of experienced persons, a 
reservoir secured to the wall with an india-rubber tube attached to it, 
by which the stream of water is conducted directly into the eye, is 
best adapted for this purpose. The temperature of the water should 
not be higher than the temperature of the room. In private practice, 
with proper care, the water may be injected into the eyes with a 
syringe ; or it is allowed to flow into them from a small, narrow-spouted 
can, which procedures must be repeated at least every hour. A toler- 
able amount of adroitness is requisite to properly manijDulate the 
syringe ; usually the nurses throw the water upon the firmly-aggluti- 
nated eyelids, and, of course, as much pus remains beneath them after- 
ward as before. I consider it very inappropriate to hold the lids apart 
by means of spatulse every time the eye is cleansed, because such an 
intense oedema is thereby produced in a very short time, that the upper 
eyelid comes to drop far down over the lower, and then it is altogether 
impossible to obtain a sight of the globe. In consideration of these 
difficulties, and because with the syringe people very often throw the 
blennorrhoic pus into their own eyes, and thereby lose their own vis- 
ion, I content myself with cutting up a fine sponge that has already- 
been in use for some time, into angular pieces and with these cause 
the eye to be sponged every half hour or hour. The aurse should 
hold the lids open with the thumb and index-finger of the left hand, 
while with the moistened sponge in the right she brushes over the 
conjunctiva. This manipulation every person with a good-will can 
learn to execute ; it also completely suffices to cleanse the conjimctivse, 
and the pillow and child's garments are not thereby soaked through, 
as is usually the case with injections. 

The Local Treatment. — Ever since Von Griife so strongly recom- 
mended the application of nitrate of silver, almost all blennorrhoic 
conjunctivae have been cauterized. First of all, it should be observed 
that, for the purpose of thoroughly cauterizing the eyes, it is necessary 
to have an assistant, who should fix the head and properly evert the 



82 DISEASES OF CHILDREN. 

eyelids.* Either the ordinary nitrate of silver or a mitigated caustic 
composed of equal parts of nitrate of silver and nitrate of potassa fused 
together is used for this cauterization. A little olive-oil or salt water 
\vill prevent the caustic from spreading unnecessarily. The secretion, as 
a rule, is somewhat checked after the cauterization ; it appears again, 
however, on the next day more profusely than ever. The eyes are 
cauterized from day to day, until the disease gradually disappears. 
Both eyelids should be brushed over every time with the caustic as far 
back as the orbital reflexion, because the whole conjunctiva palpe- 
brarum is involved in the disease. That this method of treatment is 
painful, and that for this reason the women do not bring their children 
to be cauterized a second time, cannot be denied. Moreover, I have 
often seen perforation of the cornea ensue, notwithstanding the most 
carefully carried out precepts. Blennorrhoea of the conjunctiva seems 
to be an analogous process to gonnoiThoea of the urethra. A few 
years ago surgeons were very enthusiastic over nitrate of silver 
injections in gonorrhoea too. Now, no one resorts to them any 
more. 

A collyrium of corrosive sublimate, or sulphate of zinc or of cop- 
per, gr. ss of the first, gr. j of the last two, to an ounce of water, is 
less painful and about as effectual as cauterization with the solid stick 
of nitrate of silver. One drop of any of these collyri^ is dripped into 
the inner angle of the eye, six or eight times daily; the lids are 
slightly opened, and the head is held in such a position that the drops 
will run into the eye by their own gravity. The sovereign remedy in 
the first days of blennorrhoea is 

Cold. — But to generate continuous cold upon a given spot on the 
skin is not as easy as may be supposed. Compresses dipped in cold 
water, and laid iipon the skin, assume in a very short time the tem- 
perature of the skin itself. They would therefore have to be renewed 
so frequently that more than one nurse would be reqxured. But if 
two or three bits of ice, as large as peas, are placed between the 
moistened folds of the compress, the melting pieces of ice will keep 
the temperature of the eyelids reduced for eight or ten minutes. So 
small a quantity of ice, on melting, does not generate water enough 
to run down over the cheeks, and whatever there is of it is absorbed 
by the compresses. As a sure protection against wetting the body, 
a dry cloth around the neck is very useful. By continuously-gener- 
ated cold, the oedema of the lids may generally be reduced, and the 

* [Still, the assistant may be dispensed with, by the physician securing the head of 
the child between his knees ; he then everts one eyelid, which he retains everted 
with the thumb or index-finger of the left hand, while with the right ho is at liberty 
to handle the caustic. The other eyelids are then similarly treated. See also remarks 
on the use of muriate of cocaine in the treatment of keratitis, page 584.] 



DISEASES CONSEQUENT ON DELIVERY. 83 

blennorrhoea kept within moderate bounds. By constant, scrupu- 
lous cleansing, an astringent eye-wash, and, when the secretion 
lasts longer, by the inunction of blue ointment upon the forehead, 
the cornea will be kept from perforation. Warty excrescences in 
the palpebral sinuses, where the blennorrhoea is nurtured for a very 
long time, are best removed with the scissors. If perforation and 
prolapse of the iris have taken place, staphyloma at least may be 
prevented by energetic cauterization of the cornea, and constant 
pressure. In circumscribed central leucoma, the sight at a later 
period may be infinitely improved by the formation of an artificial 
pupil. If phthisis bulbi (atrophy of the globe) has occurred, the 
deformity may be mitigated by an imitation eye, in the perfection 
of which, art of late has made such extensive progress. 

Z— MASTITIS NEONATORUM {Inflammation of the Breads). 

We conclude the chapter on the diseases of the new-born child 
with the description of a disease that affects the breasts, namely, 
mastitis neonatorum, and it very properly belongs here, for it oc- 
curs as often in new-born boys as in girls. To comprehend this 
peculiar condition, it is only necessary to premise that the breasts 
of most new-born children, when slightly pressed, will emit a small 
quantity of thin milk, which in from eight to fourteen days in 
the male child disaj)pears forever, but in the female till the first 
pregnancy. 

According to Guillot^s investigations, it is neutral or alkaline, 
but becomes acid if allowed to stand, and then separates into two 
parts. Microscopically, colostrum corpuscles are found in it in 
great abundance. It does not by any means taste sweet, but some- 
what insipid, or even salty, of which I have frequently convinced 
myself. 

This temporary secretion of milk makes the breasts of the new- 
born child as disposed to inflammation as those of suckling women. 
Pressure or a bruise, which, during the delivery, may be unavoidable, 
suffices to induce inflammation and suppuration of the breasts. Med- 
dlesome midwives are often to blame for this affection, for they make 
the inexperienced mothers believe that the milk has to be assiduously 
squeezed out. Redness and swelling of the gland results from this 
operation ; and at length, on touching the breasts, the child sets up 
a cry of pain, the swelling increases, and fluctuation is finally felt at 
some place ; and, when the abscess bursts, a large quantity of thick 
pus escapes. Suppuration lasts for a few days, after which the abscess 
closes, the gland remains for some time indurated, but, after a few 
weeks, complete restitutio in integrum has taken place. In cachectic 



84: DISEASES OF CHILDREN. 

children who suffer at the same time from thrush and diarrhoea, the 
erysipelatous redness will extend over a large portion of the thorax, 
and, after spontaneous or artificial opening of the abscesses, large 
patches of cellular tissue will slough off, and fistulous ulcerations 
will remain for a long time. The only bad effect of suppurative 
mastitis in girls is, that the nipple and even the whole gland may 
shrink up, when the mamma, thus altered, will be partially or totally 
unable to perform its function at the time when the duty of lactation 
becfiiis. 

Therapeutics. — A rational prophylaxis is the main indication. If 
the glands are swollen, but not yet reddened and painful, the transi- 
tion into suppuration, in most cases, may be prevented, if all pressure 
and irritation are carefully avoided, and the occlusion of the lacteal 
ducts obviated by inunctions of olive-oil. To accomplish the first 
indication, a fine piece of oiled linen is laid upon the breast, and over 
this some lamb's-wool. In this manner we may almost always succeed 
in reducing the cedema, and in bringing about a normal condition of 
the gland. But, if it nevertheless suppurates, the oiled linen is none 
the less useful, but the lamb's-wool should be changed for bags of dry, 
Avarm bran, because the ripening of the abscess is accelerated by them. 
In puncturing the abscess, the nipple should be avoided, for the cica- 
tricial contraction resulting from the wound will invariably pull it 
down and deform it, and this, in the after-life of the girl, may exercise 
a very unfavorable influence upon the nursing of her children. The 
incision should be in the direction of radial lines from the nipple as a 
centre. After the pus has escaped, plain, moist, warm compresses are 
applied, by which crusts are prevented from forming, and the lips of 
the wound from prematurely closing. In otherwise healthy children 
the wound will close in a few days ; in atrophic children, where col- 
lapse is vastly accelerated by the suppuration, the pus becomes floc- 
culent, and thin, and the wound remains open until death. 



CHAPTER II. 

DISEASES OF THE DIGESTIVE APPARATUS. 
K.— MOUTH. 

(1.) Harelip and Cleft Palate [Labium Leporinum — Pala- 
tum Fissiim). — Harelip is a congenital splitting of the upper lip ; 
cleft palate, a congenital fissure of the hard palate. In order to 
thoroughly comprehend these malformations, it is necessary to re- 
vert to the history of the fetal development. 



DISEASES OF THE DIGESTIVE APPARATUS. g5 

As long as the two superior maxillae remain ununited in the me- 
dian line, with the intermaxillary bone that has originated from the 
central process of the frontal bone, to form the hard palate, so long 
will the mouth and nasal cavities stand in open communication with 
each other, 

Now, in cleft palate, this union is arrested on one side ; in hare- 
lip, a union between the bones does indeed take place, but seems to 
have been retarded, on account of which, the ujDper lip, which is 
formed pi'imarily of two lateral and one central piece, does not be- 
come united ; the fissure of the upper lip, cori'esponding to the one 
in which the union has been arrested, becomes skinned over like the 
borders of the lips, and union is subsequently altogether impossible. 
From these remarks, it will be readily perceived why harelip never 
occurs in the centre of the lip, but always on one side : the chasm 
invariably terminates in one or the other nasal cavity. 

We have various grades of fissures, according to the time in 
which, during fetal life, this arrest of development has taken place. 
The cleft of the hard palate may be so wide as to easily admit a 
finger, and all the infundibuli may be inspected without any diffi- 
culty. In this intense form, scarcely any upper lip is present, and 
one or both nasal orifices are immensely distended. Or the inter- 
maxillary bone, covered with some skin, projects forward, and forms 
a knob under the nose. At each side of this bulb, fissures of the lip 
run into the nasal orifices. Or there is only a narrow fissure in the 
hard palate, which will barely admit the back of a knife, and corre- 
sponding with it, the cleft in the upper lip is also less grave. Or 
both upper jaws are perfectly normally formed, and there is only a 
narrow fissure in the upper lip, the margins of which almost touch 
each other, and either extend clear into one of the nasal openings, or 
only half way to it. 

There are families many members of which are deformed by 
harelip, so that we ai*e compelled to assume a kind of predisposition 
or inheritability. 

The effects of this evil are : 

(1.) Difficult SucJdng, particularly in Cleft Palate. — The act of 
sucking consists in the lips locking themselves hermetically around 
the nipple ; the air in the mouth becomes rarefied by the dilatation 
of the thorax, and the milk is in this manner pumped out from the 
breasts. But, when the continuity of the lips is broken, they are un- 
able to firmly and perfectly adapt themselves around the nipple, and 
infants are then incapable of exhausting the milk. When the hard 
palate is not simultaneously fissured, children will grasp the nipple 
between the jaws, instead of the lips, and in that way suck with 



86 DISEASES OF CHILDREN. 

tolerable ease. But when cleft palate is also present, then they are 
almost altogether unable to nurse ; the overflowing breasts do in- 
deed discharge some milk into the mouth, but the greater part flows 
out again at the nose ; this is best prevented by holding the head 
of the child elevated. 

(2.) Obliquity in the Position of the Teeth. — If the operation is 
not performed before the eruption of the teeth, or if it has been un- 
successful, the teeth of that part of the jaw that is not covered by 
lip will grow crooked, outwardly instead of downward ; this is es- 
pecially true when cleft palate also exists, which gives to the face a 
hideous disfigurement. 

(3.) Indistinct Speech. — Some letters, to the articulation of 
which the upper lip is indispensably necessary, principally B, M, P, 
W, are but indistinctly pronounced in harelip, and are altogether 
impossible of articulation in cleft palate. In the latter case, all the 
other consonants in addition lose in distinctness on account of the 
defect of the palate. 

Treatment. — Nothing but an operation can remedy this deform- 
ity. As regards the time when it is to be performed, much has al- 
ready been written and disputed. If the nutrition of the child is 
much interfered with, if it does not learn in the first few weeks to 
suck and swallow properly, then of course it will remain backward in 
its development, and the operation must be performed as soon as possi- 
ble. But, when this is not the case, it is best to wait until the child 
has passed the fourth month. At all events, however, the operation 
should be performed before the eruption of the teeth, for, as soon as 
dentition has once begun, children are oftener subject to sickness, and 
on that account the result often proves a failure. Moreover, children 
more than six months old begin to use their hands, with which they 
may tear down the plaster after the operation, or entangle them 
among the points of the pins, and thus frustrate its success. 

Before the operation, the child is to be kept awake for several 
hours, in order that it may subsequently fall into a deeper sleep than 
usual ; and it is also to be nursed, so that thirst or hunger may not 
rouse it too soon. It is best to wrap the entire body up to the neck 
in a sheet, and then place it in the lap of an assistant. Nothing 
more is necessary for the operation than a sharp tenaculum, a strong 
sharp scissors, the sewing apparatus, and a few strips of adhesive plas- 
ter. A second assistant now seizes a part of the split lip between 
his thumb and index-finger and compresses the vessels. The opera- 
tor, seated opposite the child, seizes hold of the border of the lip 
with the tenaculum where it passes over into the fissure upwardly, 
pushes the scissors into the slit, and with one cut removes the entire 



DISEASES OF THE DIGESTIVE APPARATUS. gt 

edge. The same manoeuvres are repeated on the other side. After 
the edges have been adjusted, two or three needles, the lower ones 
first, are introduced, and a few turns of the ligature taken around 
each one of them. 

In wide-cleft palates, where scarcely any upper lip exists, the 
cheeks will have to be separated from the bone very far backward, in 
order to obtain a sufiicient amount of distensible substance. All pro- 
jecting teeth and bony outgrowths must, under all circumstances, be 
removed before the operation, and the wounds should first be allowed 
to cicatrize. The ligature should not be drawn too tightly, for the 
circulation in the margins of the wound will thereby suffer severely, 
and an insufficient amount of plastic material will be thrown out. 
In my first operation for harelip, I drew the ligatures very tightly, 
in order to adapt the edges every accurately. In twenty-four hours 
the child was seized with trismus and tetanus, and the needles, of 
course, had to be removed as quickly as possible. The trismus then 
disappeared, but the success of the operation was frustrated. 

After from forty-eight to sixty hours, the needles, which should 
have been previously brushed over with a little oil, may be removed; 
the twisted suture may remain adherent for some time longer. In 
double harelip, with large central piece, an attemj^t should be made 
to save it. In cleft palate, where frequently one border of the notch 
is shorter than its fellow, a curved incision should be made on the 
shorter one, by which the borders of the wound will become equal 
in length. 

Even when the operation has been entirely successful, in the 
course of time, a cicatricial contraction and a visible notching of the 
upper lip result. The success of this operation is of the utmost 
importance for the future shaping of the cleft palate. The united 
upper lip then constantly acts as a mild truss upon the fissured ujjper 
jaws, approximates them more and more to each other, till they 
finally touch, when the mucous membrane, by mild cauterization, or 
by bai'ing the edges with a knife, may be brought to a union. 

(2.) CojSTstrictio^s" of the Mouth. — Microstoma (from fUKpo?, 
small, and a-roixa, mouth). — An exceedingly rare affection. Some 
children come into the world either with a very small mouth or with 
completely united lips, in which latter case it is of itself understood 
that an operation for the formation of the mouth must be undertaken 
in the very first hours of life. A more frequent occurrence is con- 
traction of the mouth from syphilitic mucous patches, and chancres. 
The cicatrices contract more and more, till, finally, it is impossible to 
introduce a small spoon, or even a tube. If the syphilis has been 
eradicated from the system by a mercurial treatment, the formation 



88 DISEASES OF CHILDREN. 

of the mouth may be undertaken according to DiffenbaclCs method. 
A myrtle-leaf-like piece of skin is excised fi-om the cicatrix, at both 
sides of the constricted mouth, without injuring the mucous mem- 
brane, thus forming the future angles of the mouth ; next the mucous 
membrane is cut through with the scissors clear to the angles, is 
lapped over the edges of the wound, and united to the outer border 
by sutures. If the subjects are not marasmic, which, however, is 
their usual lot after they have surmounted syphilis, the operation 
will readily succeed. In the contrary case, the mucous membrane 
will not heal, but becomes covered with an aphthous membrane, and 
the patients perish in an atrophic state. 

(3.) Imperfect Development of the Tongue [Defectus Lin- 
guce). — Instead of the normal oval form, the tongue occasionally dis- 
plays an indentation at the apex, or even a more extensive fissure. 
Complete splitting of the tongue, where two movable tubercles or 
bands are seen at the back of the mouth, is very rarely observed. 
Children thus affected, according to Bednar, are able to cry, and 
the sense of taste is said to be present. According to embryology, 
this malformation is explainable in the following manner : The devel- 
opment of the tongue proceeds from the first visceral arch. When 
the bulbous ends of the visceral arch meet in the median line, and 
become united to each other, a small tubercle is seen to develop itself 
on the lower border of the posterior surface of the first gill-arch, at 
the place of union of the two halves, which at first has a triangular, 
later an oval form, and gradually becomes developed into an ante- 
rioi'ly-curved, fleshy cone (the tongue). But, if this union of the 
visceral arch did not take place perfectly, and at the right time, that 
fleshy cone will remain divided, and, as an effect thereof, is retarded 
in its general development. 

(4.) Hypertrophy and Prolapse of the Tongue (Prolapsus 
Lingum). — The tip of the tongue only is seen protruding beyond the 
lips at birth ; the protruding piece, however, if nothing is done, will 
increase in size from day to day. Such children are unable to suck, 
and also hindered in swallowing, for the tongue not only hypertro- 
phies anteriorly, but also in width and thickness. This enlargement 
of the tongue is usually combined with cretinism. When the denti- 
tion period arrives, the incisors are prevented from assuming their 
perpendicular position, and are directed obliquely forward. The 
constant pressure of the teeth produces an intense infiltration of the 
tongue : it ulcerates, becomes furrowed, the saliva constantly flows 
down over it, undergoes decomposition, and diffuses a disgusting, 
sour, rancid, fatty smell. In cases of many years' duration, the in- 
ferior maxilla forms a gutter, in which the ulcerated or dry tongue 
lies; The lower lip becomes everted, and the acquisition of distinct 



DISEASES OF THE DIGESTIVE APPARATUS. §9 

speech is wholly impossible. This condition is also met with in 
children well-developed in other respects, who have frequently suf- 
fered from convulsions, by which a weakness or partial paralysis of 
some of the muscles of the tongue may remain. 

Treatment. — If the evil is recent, and the tongue reducible, the 
cure is soon effected by dusting powdered alum on the protruded 
part, or painting it with tr. amara. But, when the tongue cannot be 
reduced in this manner, and the mucous membrane is already ulcer- 
ated and fissured, the projecting piece will have to be removed by a 
surgical operation. Hitherto, the ligature or knife was employed 
in this operation ; in most instances it is now performed with the 
ecraseur, but most quickly and elegantly with the galvano-caustic 
apparatus. 

(5.) Abnormal Adhesions of the Tongue [Adhcesio Lingiioe). 
— There are cases in which the f rsenum is short, and yet inserted very 
far anteriorly at the tip of the tongue, by which that organ is much 
hindered in its motions, especially in its protrusions, and in sucking. 
Tubercles in and hypertrophies of the frgenum also occasionally oc- 
cur, and exercise the same effect upon the tongue. Frseni, which 
are so constructed, must be severed by the snip of a scissors, if the 
sucking has actually been interfered with ; this, however, is usually 
not the case. The frsenum is divided hundreds of times where it is 
once really indicated. But, as this operation, when performed by a 
steady hand, is totally devoid of harm, it is therefore not necessary 
to look so strictly for the indications, especially if any comfort can 
thereby be conferred upon the patients. This little operation is 
performed in the following manner : The head of the child, facing 
the window, is held by some person, while the surgeon pushes the 
index-finger of his left hand under the tongue, close by the franum, 
makes the latter a little tense, and cuts it through with a curved 
Cooper's scissors as far as it is membranous. The haemorrhage 
soon ceases. 

But, in addition to this shortening of the frgenum, there also oc- 
curs an actual union of the whole lower surface of the tongue on all 
sides with the floor of the mouth, either congenital, as a continua- 
tion of the embryonic union of the tongue with the floor of the 
mouth, of which the normal superfluity of the folds of mucous mem- 
brane on both sides of the frenulum represents the so-called plica 
fimbriata, or acquired through syphilitic or mercurial ulcerations. 
Fortunately, this is a tolerably rare occurrence. The separation of 
the entire tongue with the knife is a very bloody operation, and 
often leads to no satisfactory results, if the after-treatment, con- 



90 DISEASES OF CHILDRExV. 

sisting in the constant introduction of pledgets of lint, and frequent 
passive motion of the tongue, is not assiduously carried out. The 
galvano-caustic promises better results. 

(6.) Ra^tula. — By ranula, frog-swelling, we understand a cystic 
tumor with fluid contents, found beneath the tongue on the floor of 
the mouth. It occurs on one or both sides of the frtenuluni linguae, 
its size varies between that of a pea and a pigeon's egg ; in the latter 
case, it may also be felt externally beneath the chin. The mucous 
membrane covering it is often so atrophied that the walls of the cyst 
lie freely exposed. In other cases, the tumor lies much deeper on 
the anterior and lateral parts of the neck under the mylo-hyoid 
muscle. The effects of this evil vary according to its size. So long 
as the tumor is not larger than a pea, it gives rise to no phenomenon. 
But, as it increases in size, it compresses the tongue against the hard 
palate, and then sucking, swallowing, and breathing are rendered 
diflicult. In the most intense form of this evil, attacks of suffocation 
ensue which have some resemblance to those of croup. It is gener- 
ally supposed that this affection can only be cured by a surgical 
operation ; but a spontaneous cure may also take place by suppura- 
tive degeneration of the cyst and its adjacent structures ; of this, 
the following case taught me : 

A mother rushed bi'eathless into my office, with a boy one and a 
half years old in her arms. She related that he had always been 
well, but of late had a peculiar rattling in the throat during sleep, 
and, for the last eight days, attacks of suffocation, which, accord- 
ing to her ideas, had some connection with the dentition, because 
he was suffering from profuse ptyalism, and often put his hand 
into the mouth. While the woman w^as making these statements, 
I commenced to examine the child. The forehead was hot, the 
pulse very rapid, the respirations loud, like those of croup, the ex- 
pression of the face anxious and suffering. As I introduced my 
finger into the mouth, for the purpose of examining the pharynx 
and tonsils, he was seized with a sudden fit of choking, and, as I, 
on that account, depressed the tongue, I felt something burst, and 
the size of the tongue instantly decreased. At the same time, a 
tolerably large quantity of muco-purulent fluid flowed alongside of 
my hand from the floor of the mouth, which had its source in the 
ruptured cyst beneath the tongue. I thoroughly cauterized the 
collapsed cyst with lunar caustic, and it became converted into 
an obstinate ulcer, which healed, only after many months, with a 
white cicatrix. 

Various theories are entertained in regard to the nature of ranula. 
Aside from the somewhat too keen theory of old Pare, who con- 



DISEASES OF THE DIGESTIVE APPARATUS. gl 

sidered it " as cold, moist, gelatinous matter derived from the brain, 
and transplanted to the tongue," it is looked upon by some as a 
cystic swelling of unknown origin ; while others regard it as an 
occlusion, and subsequent distention of the duct of the submaxillary 
gland, the ductus Whartonianus. This latter theory, suggested by 
Muninchs, and adopted by many others, has too serious grounds 
against it to retain any further value. A priori reasoning would 
favor this supposition ; it finds a justifiable analogy in the dacryocys- 
toblennostatis, but chemical investigations have shown that the fluid 
of the ranula is not saliva, for albumen is found in it, which does 
not exist in saliva, while rhodium-kali, characteristic of the latter, is 
here totally absent. The reply, that the chemical synthesis may not 
be able to produce the exact proportions, because the saliva, long con- 
fined, may take up new chemical bodies, and, by exosmosis, give off 
primitive ones, is made invalid by the anatomical knife. Accord- 
ing to Hyrtl, ranula has already been found near the healthy un- 
dilated salivary duct. Ranula, consequently, is no dilated ductus 
Whartonianus, but a cyst ; and, since, according to Fleischmann, a 
mucous bursa exists under the tongue, it is probably a dropsical 
mucous bursa, or ganglion. 

The prognosis, according to these anatomical conditions, and 
also in conformity with experience, is not unfavorable, chiefly be- 
cause the diseased parts are within easy reach. 

Treatment. — It consists in the removal of the anterior part of the 
cyst, and frequently-repeated cauterizations of the opened cavity 
with a solid stick of nitrate of silver. A simple incision into the 
cyst and evacuation of its contents do not answer, because the cyst 
is very prone to close up again ; this is still more promoted by the 
pressure of the superlying tongue. A very torpid ulcer results from 
the cavity that is thus exposed, which does not close up until it has 
been repeatedly and intensely cauterized. 

(7.) Catarrhal iNPLAMMATioisr of the Mucous Membraiste of 
THE Mouth [Stomatitis Catarrhalis). Symptoms. — By catarrhal 
stomatitis are meant redness and augmented secretion of the mucous 
membrane of the mouth. On those places of the mucous membrane 
which have a feeble and rich substratum of connective tissue, the 
redness attains to a much higher degree than on those which lie 
directly over the bone, for example, on the hard palate, Avhere it is 
generally but slightly increased. It is most intense on the tongue, 
which has the appearance as if it were covered over by a thick coat- 
ing of raspberry syrup. When the process lasts long, the tongue 
becomes covered with a white fur. In fact, even cedema of the 
mucous membrane supervenes here ; it is, however, so slight, that it 



92 DISEASES OF CHILDREX. 

produces no change in the form of the cheek and lips, as is the case, 
for instance, in stomacace. 

The pain is here very distinctly marked. The patients suck un- 
willingly ; partake on the whole of but very little, and only cold nu- 
triments, and do not allow their mouths to be felt with the finger. 
As this stomatitis catarrhalis is but very seldom idiopathic, and gen- 
erally the accompaniment of other, in greater part febrile processes, 
it is difficult to determine its influence upon the general state of the 
system. Nervous children are also feverish in simple stomatitis, al- 
though unaffected by any other disease. When the inflammation of 
the mucous membrane of the mouth extends over the larynx, nasal 
passages, the Eustachian tube, and tympanum, it produces the well- 
known phenomena of catarrhal laryngitis, coryza, catarrh of the Eu- 
stachian tube and of the tympanum, any one of which suffices to in- 
duce febrile excitement. The pain, during nui'sing and drinking, at 
times is so great, that children will partake of scarcely any nutriment 
for days ; nutrition and development are thus totally interfered with. 

The secretion of such a morbidly-changed mucous membrane is 
always augmented, the saliva constantly flows out at the corners of 
the mouth, corrodes them, reddens the chin, and soaks through the 
garments. This saliva does indeed smell somewhat acid, and reacts 
also feebly acid ; it never, however, has that disgusting odor which 
is perceived in actual suppurations of the mucous membrane. 

If the redness and painfulness have existed for some time, and 
the cause still continues, clear, minute water-vesicles, like true ex- 
udations, will rise upon the tongue, gums, raucous membrane of the 
lips and cheeks, which in appearance and course have many simi- 
larities to herpes labialis. They burst very soon, and leave behind 
them small, flat ulcers, with yellowish-w^hite bases, which, in the 
first few days, increase in every direction, become confluent, and 
thus present tolerably extensive ulcerated surfaces, especially on 
the edges of the tongue and on the raucous raembrane of the lips — 
stomatitis ulcerosa. — These minute vesicles, like almost all diseases 
of the mouth, have been called " aphthae," a term that has produced 
so much confusion, in the description of the diseases of the mouth, 
that it seems advisable to discard it altogether. 

After these ulcers have continued to increase in size for several 
days, and produced severe pain when touched, the yellowish color 
of their bases disappears ; they become red, and covered as it seems 
directly with epithelium ; at any rate, the recovery takes place so 
rapidly, often in two or three days, that a cure by cicatrization, 
and contraction, is not supposable. 

These ulcers never diffuse any particular odor. The breath of 



DISEASES OF THE DIGESTIVE APPAKATCS, 93 

those affected with it smells only slightly acidulous, never nause- 
ating, as in stomacace. 

The most common cause is the eruption of the teeth. During 
this process stomatitis occurs so regularly, that it must be regarded 
as physiological. A further frequent cause is to be found in the 
sugar-teat with its fermenting contents. In older children, too hot 
or too cold nutriments, carious teeth, spiced, irritating victuals, in 
some children antimonial and iodine preparations, may also give 
rise to this affection. It also occurs in small epidemics, chiefly in 
summer, caused perhaps by the immoderate indulgence in sour 
fruits ; and, in addition, is also the accompaniment of many febrile 
diseases, especially of the acute exanthemata. 

Treatxnent. — The treatment is extremely simple. The causes, 
the sugar-teat, etc., are removed as well as possible, the chest is 
protected against getting wet by a piece of oil-silk which is secured 
under the jacket, and the infants are only allowed to drink cow's 
milk with water. 

It is advisable, on account of the profusely secreted saliva rap- 
idly becoming sour, to cleanse the mouth every hour with a feebly 
alkaline solution ; for instance, borax 3 j, to water f j. The pain- 
ful ulcers may be relieved for many hours, and even permanently, 
by cauterizing them with the solid nitrate of silver. In idiopathic 
stomatitis spontaneous recovery takes place in eight, ^i the longest 
fourteen days. Symptomatic stomatitis in febrile diseases is not 
usually a subject of special treatment. 

(8.) Putrid Sore Mouth [Stomacace). — I have never yet had 
an opportunity to see the commencement of stomacace, and conse- 
quently can neither indorse nor contradict the assertions of authors, 
according to which a catarrhal stomacace is present at first. Sto. 
macace that is already fully develoj)ed — for only against this is 
medical assistance usually sought — is attended by the following 
symptoms : 

The borders of the gums in some places are yellow, coated with 
a thin layer of yellow mucus, and their sharp margins have disap- 
peared, owing to which the teeth seem to be a little larger than 
before. The slightest touch on such a gum causes bleeding of the 
ulcerated places. Notwithstanding the slight amount of space in- 
volved in the ulcerative process, the affection can be recognized at 
a distance of many inches by the sense of smell. Stomacace always 
emits a pecidiar fetid smell, and it is by the aid of this odor that 
we are able to differentiate it with ease and certainty from the 
higher stage of catarrhal stomatitis, where, after the minute vesicles 
have burst, small, flat, yellow ulcers also take place. 



94: DISEASES OF CHILDREN. 

In this, the first degree of stomacace, the mucous membrane of 
the mouth is but slightly swollen, and its secretion not materially 
increased. 

In the second higher grade, the parts lying in contact with the 
gums become immediately infected and undergo the same morbid 
changes as the gums. The mucous membrane of the cheeks swells 
% up intensely, so that the impression of the individual teeth is very 
distinctly seen upon it ; so also the mucous membrane of the tongue, 
which upon its upper surface is covered with a white fur, and its bor- 
ders exhibit the dental imjDressions. PI. III., Fig. 1, represents the 
contour of such a tongue. Also its whole periphery, in consequence of 
the swelling and compression by the upper and lower rows of teeth, 
becomes sharply angular. The same kind of yellow ulcerations now 
form on the cheeks, lips, and tongue, as were originally only present 
upon the gums. The swelling rapidly increases. As a result of this 
the patients are no longer able to shut the mouth, they keep not 
only the lips open but also the jaws, in order to prevent the touch- 
ing and friction of the extremely painful ulcers, and a brownish-red, 
foul-smelling saliva flows doAvn in large quantities over the swollen 
lower lip. Here, too, the cervical glands become painful and swollen 
almost as regularly as in diphtheritic oris. I have never yet observed 
membranes to foifm upon the ulcers. This disease has but a slight 
tendency to heal spontaneously ; the oedema, the ulceration, and the 
fetor, may remain untreated for months, the teeth then become loose 
and fall out, and the children seriously emaciated. Finally, after a 
long time, spontaneous healing seems to ensue. 

Mastication, deglutition, and speaking, ixi the more serious form, 
become almost altogether impossible ; the patients will not drink for 
a long time, till the thirst becomes insupportable, and then they 
will consume large quantities of cold water or cold milk at a draught, 
under evident pains. In older children fever does not usually come 
on ; the pain, however, at every movement of the mouth, and par- 
ticularly on swallowing, makes them ill-humored in the highest 
degree. 

The etiology is a manifold one. The contagiousness of the dis- 
ease may be very clearly and explicitly demonstrated. Some of the 
children of a family or neighbors upon the school-benches very readily 
impart it to the rest. A stage of incubation, as in the exanthemata, 
does not seem to exist, if at all, but for a very short time ; at any 
rate, I have always noticed it to appear tolerably simultaneously in 
many families. Moreover, it may also originate spontaneously in chil- 
dren as in adults, for which carious teeth are the predisposing agents ; 
and, finally, there is a disease of the mouth in small children, produced 



DISEASES OF THE DIGESTIVE APPARATUS. 95 

by calomel^ which can in no way be distinguished from the stomacace 
just described ; it is then that the absence of the properties of infec- 
tion of the so-called stomatitis mercurialis becomes valuable as a dif- 
ferential sign. 

Diseases of the mucous membrane of the mouth, caused by me]> 
cury, occur in children less frequently and much later than in adults. 
I have never yet seen stomacace to supervene as a result of the ex- 
ternal application of mercury in the form of blue ointment, although 
I have used it for the last three years in all syphilitic children, when- 
ever the state of the skin allowed. In small children, salivation is 
an extremely rare phenomenon. 

Treatment. — We are so fortunate as to possess but one remedy 
for stomacace, and that is cJdorate of potassa^ Jcali chloricum. To 
children under one year of age, I give 3j daily; under two years, 
3 ss ; under three, 3 ij : children who have attained the fourth yeai 
tolerate very well 3 j pro die. The various quantities are always 
dissolved in four ounces of water, sweetened with a little syrup, and 
administered in from twelve to eighteen hours. After the end of 
this time, the smell, in all cases and in every degree of stomacace, is 
completely abolished. In cases of less extensive ulceration, a recovery 
instantly takes place, the gums become firm, the yellow border is cast 
off, touching with the finger no longer causes bleeding, and the pa- 
tients are again able to masticate and speak vnthout pain. Even in 
the more severe form, the use of chlorate of potassa for one day will 
sufifice to annihilate the odor completely, but, if the remedy is not 
continued for three or four days, it will return, and the disease pro- 
gress anew. I have never yet employed this remedy longer than 
four days in any one case, and have never been able to perceive 
from it any bad effects, such as diarrhoea, loss of apjDetite, ab- 
dominal pains, renal troubles, etc., notwithstanding the hundreds 
of times that I have employed it, and therefore have not prevailed 
upon myself to use it as gargle, instead of administering it inter- 
nally, especially since small children are such poor adepts at gargling, 
and even the larger ones can only with difficulty be induced to do 
it. It is entirely unnecessary to cauterize the ulcers on the cheeks 
and gums which are devoid of smell, and are no longer painful, for 
the cure progresses extremely rapidly without it. Formerly it was 
supposed to be necessary to extract all the carious teeth, of which a 
number are often found in children, before the commencement of the 
second dentition, in order that a cure might take place. It is, how- 
ever, entirely unnecessary, and even directly injurious, for the lacer- 
ated borders of the gums in the vicinity of the extracted teeth im- 
mediately become affected by the stomacace, and the pain and sup- 



96 DISEASES OF CHILDREN. 

purating surfaces are thereby only increased. Alocal treatment, be- 
sides the internal administration of chlorate of potassa, is altogether 
superfluous. 

(9.) Scorbutic I^tlamisiation" op the Mucous Mejibeane of 
THE Mouth. — By scorbutus we xmderstand a diffused disease of the cap- 
illaries, which burst at various places, and, according to the extent of 
the solutions of continuity, allow larger or smaller quantities of blood 
to be extravasated into the surrounding textvires. Whether the chemi- 
cal quality of the blood is at fault here is not ascertainable ; this 
much, however, is known, the fibrine of the scorbutic blood coagulates 
slower than that of the normal. 

Now, these haemorrhages in the mouth take place in such a char- 
acteristic manner, that the existence and degree of the scorbutus may 
be inferred from them alone. 

I can only make some allusions to the land-scurvy from my own 
experience ; how children are affected by the sea-scuny is beyond my 
means of determining. A healthy, well-nourished child, in a good 
dwelling, never becomes scorbutic. Among the more affluent classes 
it is onl}^ seen as a sequela of severe, protracted diseases, especially 
typhus abdominalis ; among the poorer classes, whole families become 
scorbutic from living in damp houses and existing upon poor and in- 
sufEcient food. 

Symptoms. — Paleness, loss of flesh, sadness, or a protracted typhus 
fever, usuall}'^ precedes, for a long time, the breaking out of the scor- 
butus. Then the gums begin to be painful on mastication, and are 
greatly inclined to bleed. The external border of the gums hes no 
longer in close contact with the teeth ; it is somewhat swollen and of 
a bluish-red color, and at some places abrasions of the mucous mem- 
brane are seen. 

The rest of the mucous membrane on the hard palate and cheeks 
is not affected by catarrhal stomatitis — it is only pale and angemic. 
Here also the fetor of the mouth is tolerably intense, nevertheless 
it can be distinctly distinguished from that of stomacace. 

When the process lasts for a long period, the entire border of the 
gum will present the appearance of a single, bluish-red extuberation, 
covered with small excrescences, and bleed at the slightest touch. 
The teeth are coated with a yellow mucus ; a brownish, fetid saliva 
flows from the mouth ; large and small ecchymoses now appear 
upon the mucous membrane of the tongue, cheeks, and lips ; at 
some places they are absorbed, at others however, they become 
ruptured, and then display fungous ulcers with readily-bleeding 
bases. Under favorable circumstances all these morbid lesions pass 
through a retrograde metamorphosis, though only very slowly, it is 



DISEASES OF THE DIGESTIVE APPARATUS. 97 

true, and the gums retain their disposition to bleed for a long time. 
But if the unfavorable causes continue, then all the scorbutic symp- 
toms become aggravated, the teeth fall out, vs^hole pieces of the gums 
are cast off, the ecchymotic lower extremities become oedematous, 
general dropsy supervenes, and the children perish with anaemia. 

Therapeutics. — The treatment of idiopathic scurvy, that has origi- 
nated through impoverished circumstances only, is very simple, if it 
is possible to improve these conditions ; that is, to put these 
children in a dry, well-ventilated room, and to procure for them clean- 
liness, care, and good attention, and in part animal food. In the con- 
trary case, all the highly-eulogized remedies will fail us. True, 
recoveries also occur here, especially in the warm seasons of the year, 
when the patients are at least able to enjoy the fresh air on the 
streets. Lemon-juice, or some kind of vegetable acid, is everywhere 
recommended as the most useful remedy. The affection of the 
mouth is readily subjugated by astringent gargles, composed of alum, 
tannin, rhatania, catechu, etc., to which a few drops of the tincture of 
mp-rh may be added with advantage. Profuse hemorrhage must be 
arrested by liq. ferri sesquichlor., or by cauterization with lunar 
caustic or concentrated muriatic acid. When gangTcnous destruction 
sets in, the powers of the system should be supported by wine, 
quinine, tonics, and good diet. Scorbutus, after typhus fever, is one 
of the most disagreeable complications of that disease. Owing to the 
great prostration of the functions of absorption, all methods of nourish- 
ment, as a rule, prove futile. 

(10.) Noma (from w/^v, corroding ulcer). — By noma, cancer aquat- 
icus (Wasserkrebs), gangrsena oris, stomato-necrosis, a gangrene of 
the cheeks is understood, which makes its appearance under such 
constant and peculiar phenomena that it demands a separate descrip- 
tion and classification as a special kind of gangrene. The older 
writers on medicine do not seem to have been acquainted with it ; the 
first work upon this subject is by JBattiis, a Dutch physician, at the 
commencement of the seventeenth century. 

Noma occurs almost invariably in children between the ages of 
two and twelve years. Nxirslings seem to be entirely exempt from it. 
Adults, too, are but extremely rarely attacked by it ; many ph3'-sicians 
have never seen it in the latter. A protracted febrile disease, scarlatina, 
measles, or typhus fever, always precedes the noma, and no instance is 
known of a previously perfectly healthy child becoming affected by it. 
It does not occur in an epidemic form ; it is asserted that it never 
appears in the southern countries ; it seems most frequently to prevail 
in Holland; girls are oftener attacked by it than boys, and almost 
always only one-half of the face is implicated. 



98 DISEASES OF CHILDEEX. 

Symptoms. — Noma is always situated in the cheek, and most fre- 
quently on that part thereof lying adjacent to the angle of the mouth. 
I have only once seen an acute gangrene originate in the deeper 
structures beneath the lobe of the ear, which, like the ordinary noma, 
quickly spread through the deeper structures of the parotid, and later- 
ally over the cheek, neck, and lobe of the ear, and in a few days 
brought about a lethal end. Usually, a child convalescing in the very 
best manner presents a tolerably distinct, circumscribed, indurated spot 
on the cheek near the angle of the mouth, Avhich causes no very great 
amount of pain. On inspecting the mouth, a serous vesicle is seen 
only exceptionally opposite the induration ; usually it is ruptured, 
and the mucous membrane has undergone a brownish-black, shreddy 
decomposition. 

The cheek swells up, and the adjacent glands of the neck become 
infiltrated. The integument of the cheek is pale, waxy, and glisten- 
ing, and the portion covering the place of the first induration, oppo- 
site to the internal disorganization, turns blue, the epidermis becomes 
flaccid, is detached with the utmost ease, or falls off of its own accord, 
and now it is seen that the gangrene, progressing from within out- 
ward, has reached the skin. At first, the gangrenous part of the cheek 
is barely of the size of a nickel penny, and contracts by desiccation, 
then a brownish-red furrow forms between the li\T[ng and mortifieii 
skin, and this furrow extends peripherally more and more, so that the 
gangrenous part may be seen to increase in circumference from hour 
to hour. The gangrene extends further and further, till in some cases 
the entire cheek up to the eye, to the ear, and to the cervical region, 
has become involved, and the patient presents a disgusting picture of 
horribly-destructive disease. The noma does not merely extend exter- 
nally, but it also attacks the bones of the jaws ; the upper (sometimes 
also the lower) maxilla rapidly becomes necrotic, the teeth fall out, and 
after a few days the necrosis is so complete that large pieces of bone 
may be removed \nth the dressing-forceps. A fetid sero-sanguinolent 
ichor flows from the irregular, ulcerated, sloughing surface, Avhich is 
but little sensitive. The borders of the sound parts are reddened, 
several serous vesicles sometimes form upon the apparently still 
healthy cheek, at a distance of a few lines from the gangrenous spot, 
the subjacent tissues rapidly mortify, and the borders of the new and 
of the old vilcers approximate each other closer and closer, till they 
finally form one large gangrenous, phagedenic surface. On examin- 
ing this mortified Jjart, a large quantity of free fat Avill be found mixed 
with traces of muscle, the nerves are yellowish white, and the blood- 
vessels are filled with thrombi. The thrombi seem to have formed 
very early in the disease, and in a very severe degree ; for hasmor 



DISEASES OF THE DIGESTIVE APPARATUS. 99 

rhages are extraordinarily rare occurrences here. This intensely de- 
structive process runs its course in from three to six days. 

The general phenomena and fever are, at first, insignificant, and 
appear only as consequences of the local destruction and purulent 
absorption ; soon, however, diarrhoea of a colliquative nature comes 
on, syncope, sopor, or delirium, becomes superadded, and the feet, as 
a finale, become oedematous. At the autopsy, we generally find, in 
addition, lobular pneumonia, which, during life, on account of the ex- 
treme prostration of the whole organism, manifested but few objec- 
tive and subjective symptoms. Noma is easily diagnosticated. It is 
difierentiated from all other kinds of stomatitis by the rapidity with 
which the external structures become involved, and the rapid spread- 
ing of the gangrene. The prognosis is very bad. Out of five cases 
that came under my observation, one only recovered, and that, too, 
with a frightfully-disfigured nose and cheek, which were only partly 
remedied by several plastic operations, but not without great distor- 
tion of the adjacent parts. According to a compilation by Tourdes, 
sixty-three out of two hundred and thirty-eight cases recovered. 

Treatment. — Chlorate of potassa may also be given in this disease, 
with the object of ameliorating the fetor, in the same manner as rec- 
ommended in stomacace. Here, however, the effects of this remedy 
are not so brilliant ; the gangrene keeps on progressing, and the odor 
is but slightly diminished. In order to abate it as much as possible, 
it is necessary to bathe the children daily, and to change their gar- 
ments often, because they constantly wipe their ichorous, soiled 
hands upon them. An attempt must be made to arrest the progress 
of the gangTcne by cauterizing the healthy parts contiguous to it. 
Concentrated muriatic acid, with which the whole border of the 
noma, internally and externally, should be pencilled over two or three 
times daily, seems to be the most appropriate escharotic. The child 
should be firmly held by an assistant, for the pain is very severe, and 
all the superfluous acid on the surface of the mucous membrane of the 
noma should be wiped away with a small sponge. In this manner it 
is possible, in some cases, to keep the evil within bounds. In most 
cases, however, the gangrene progresses unrestrained, and the patients 
perish in from two to fourteen days with the above-described symp- 
toms. Not much can be accomplished with a stimulating treatment 
of wine, decoct, cinchonte, eggs, etc., for usually it is impossible to in- 
duce them to partake of such nutriments ; milk or coffee is about the 
only article of diet for which they have any relish, of which as much 
as possible should be administered to them. 

(11.) Thrush. — By thrush, sprue, soor (Mehlmund, Mundsohr), 
muguet, blanchet, of the French, aphthae, stomatitis cremosa, aph- 



too DISEASES OF CHILDREN. 

thophyta, by all these diflFerent designations only one process is 
understood, namely, the formation of white membranes in the mouth, 
which, microscopically, consist (1.) Of a granular mass, (2.) Of base- 
ment epithehum, and (3.) Of fungi in their various stages of develop- 
ment. (PI. TIL, Fig. 2.) Robin has called this fungus oidium 
albicans. The views of the different authors on the nature of this dis- 
ease vary in many respects, at the present day, although it occurs 
extremely often, and almost daily presents itself for examination to 
every physician, and although the mouth is accessible to all the senses. 

Thrush attacks, by preference, infants in the first months of life, 
but in some instances it has also been observed in children one or 
more years old ; in addition, also, in cachectic adult indi^aduals, and 
especially tuberculous and carcinomatous patients. 

Symptoms. — At first the natural bright-red color of the mouth 
becomes altered, a livid, dark-red color takes its place ; the entire 
mucous membrane appears as if a thick layer of raspberry syrup had 
been smeared upon it. This change of color never occurs in the 
form of spots or islands^ but is imiformly difiused over the entire 
cavity of the mouth. Only on the hard palate, where the mucous 
membrane is firmly adherent to the bone, and on the border of the 
lower jaw, where the teeth which are near breaking through cause a 
marked tension and attenuation of the super-lying mucous membrane, 
no such decided dilatation of the capillaries can take place, and it is 
on that account that the redness is less developed there ; sometimes 
there is a marked contrast between the entire yellowish-red hard 
palate and the rest of the livid-red mucous membrane. The tongue 
is darkest in color, and its papillae, particularly those at its margins, 
are a little more prominent than usual. The temperature of the 
mouth, according to the sense of touch, is slightly increased ; no 
exact thermometric measurements can be obtained in children. The 
mouth, at the same time, becomes painful to the touch, as is apparent 
from the efforts of the infants to expel every foreign body introduced 
into it. In the normal state, for example, when a finger is introduced 
into the mouth, they instantly begin to suck at it ; but, when affected 
with this disease, they will try to remove it by rolling the head from 
side to side, and will also begin to cry. For the same reason they 
cften stop during nursing, and rest for a while, from the pain to the 
inflamed mucous membrane, caused by swallowing. 

Further on in the disease an anomaly in the secretion of the 
mouth takes place. The mucous membrane loses its lubricity, feels 
tenaciovis, and a piece of filtering paper laid upon it sticks to it ; in 
the normal condition, the filtering-paper does not readily adhere to it. 
Tlie distinctly acid reaction of the secretion of the mouth, at a time 



DISEASES OF THE DIGESTIVE APPARATUS. IQl 

when as yet none but these changes of the mucous membrane can 
be perceived, is of the highest importance, and supplies an index in 
judging of the entire morbid process. 

In the mouth we have a mixture of two glandular secretions, 
namely, the secretion of the salivary glands and of the mucous folli- 
cles. Pure salivary glandular secretion always reacts alkaline, and, 
indeed, most distinctly so, immediately after a meal. The secretion 
of the mucous follicles very soon becomes sour, and this acid reaction 
is always more distinct when the fresh mucus is alloAved to stand, for, 
owing to the fermentation that takes place, free acid is rapidly 
generated. We have, then, two diametrically opposite reacting 
fluids in the mouth, and it -will depend upon their quantitative rela- 
tion to each other, and their degrees of concentration, whether the 
mixture should possess more of the properties of saliva or of mucus. 
If a sufficient quantity of alkaline saliva is present, the free acid de- 
veloping in the mucus is thereby neutralized; if not, a distinctly 
acid-reacting secretion of the mouth originates. 

The tenacious, highly-red mvicous membrane, at the commencement 
of thrush, always reacts acid, even if it has been cleansed in water 
and not been in contact with any food for a whole hour. If any mucous 
membrane so constituted is scraped off, and the raspings examined 
by the microscope, there is found, conjointly loith the ejnthelium, a 
considerahle qucmtity of oval, sharply-defined bodies, sometimes con- 
nected together in tioos or threes, which are easily recognized as 
fungous spores. True, a highly-red, acid-reacting mucous mem- 
brane is also met with, where it is not possible to detect upon it 
any of these spores ; I have, however, never succeeded in discovering 
them upon a normal, pale-red mucous membrane that had been well 
cleansed in water, and had not been in contact with any food after- 
ward. From this it follows that the disease of the mucous mem- 
brane primarily originates without the formation of fungi, and 
that no fungi ever form upon normal mucous membrane. These 
fungi do not produce the acid reaction and redness, but the chem- 
ically-altered glandular secretions accumulate in the mouth, irritate 
the mucous membrane, redden it, make it hot and painful, and 
transform it into a soil favorable for the extuberations of the fungi. 
The cryptogamous growth makes as rapid progress in the mouth as 
upon any foul, vegetating surface, only with this difference, that here 
the soil does not become altered again, whereas, there it belongs to 
a living organism, and therefore never stops for a moment to regen- 
erate itself from below, and from becoming cast off on the upper 
surface. 

On inspecting the mouth, small white points will be seen, if the 



[02 DISEASES OF CHILDREN. 

cryptogamous growths have only existed for a few hours ; they soon 
become confluent at some places, form large patches, and often cover 
the entire mucous membrane with a thick white scab, which, on 
drying, turns yellowish from contact with the air, and may even 
become brown through an admixture of blood. Much difference 
of opinion has existed hitherto regarding these membranes ; the man- 
ner of their adhesion to the mucous membrane, their relation to the 
epithelium, and the jDlace of their primitive appearance, have been 
much disputed. 

First of all, as regards their connection with the mucous mem- 
brane itself, it is claimed by some that they may be detached from 
the subjacent mucous membrane without producing any haemor- 
rhage ; others deny this ; both, however, are right. It all depends 
upon the time after their origin that the attempt is made to detach 
them. Shortly after their appearance they are really very firmly con- 
nected, and cannot be detached, even by an experienced hand, with- 
out inducing haemorrhage ; but, after a few days, they become loose, 
and the mothers will easily remove large patches with the finger 
without causing pain or haemorrhage. 

In order to answer the question in reference to the epithelium, I 
must, in the first place, review more minutely the microscopic condi- 
tion of these membranes. There are seen, in every thrush-membrane, 
spores, spore-bearei's, thallus filaments, and basement epithelium, all 
surrounded and enveloped in a -white, finely-granular substance, 
from which, on the borders only, these structures can be made to 
project by squeezing. If successful in detaching a large piece, and 
its surfaces can be distinguished and separately examined, then, on 
the upper surface, mostly spores will be fovmd, fewer thallus fibres, 
and many fuUy-developed basement epithelium-cells ; on the lower 
surface, the one facing the mucous membrane, less or no basement 
epithelium-cells at all, fewer spores, but a dense structure of thallus 
fibres, which permeates throughout the whole finely-granular mass. 
If a piece of thrush-membrane is kept for a day in a concentrated 
solution of carbonate of potassa, its epithelium will be the first to 
disappear ; the white granular mass becomes more homogeneous, 
more transparent, and is recognizable at some places only ; the 
thallus fibres, however, the dense structure of which may now readily 
be discerned throughout the whole thickness of the membrane, have 
undergone no change. 

On some of the yellow places of the membranes a diffused color- 
ing matter is seen, dyeing the finely-granular mass yellow ; it is in- 
debted, for its origin, to small haemorrhages. Two kinds of thallus 
fibres may be distinguished : 



DISEASES OF THE DIGESTIVE APPARATUS. 103 

(1.) Broad with transverse strise, very much after the manner of 
yeast fungi ; and (2.) Narrow, with scarcely any striae. The latter have 
no well-defined contours, are slightly granular, and are seen every- 
where and in all cases, whereas the first kind is only exception- 
ally found. These spores flourish not only in the mouth, but grow 
also on other moist fermenting surfaces, upon a slice of an apple, 
for instance, as I have illustrated by experiments. {Henle and 
Pfeufer's Ztschrft. N. F. VIII. 2. Heft.) Erosions upon the exter- 
nal part of the lip, and even the anus, may become covered with it. 

From all that has been said, the origin of the white membranes, 
and the relation of the fungi to them, may be regarded in the follow- 
ing manner : The first thallus filaments grow upon and between the 
uppermost epithelial layer ; seek everywhere, like the roots of a tree 
on stony soil, for favorable space and ground, and finally lock in the 
entire epithelial strata, in a densely-fungous texture. Having reached 
the upper, the epithelial surface of the mucous membrane, they 
stimulate it to increased secretion, or, at least, aggravate the irri- 
tation caused by the acid reaction of the fluids of the mouth, and, 
henceforth, no complete epithelium-cells are formed from the blastema 
secreted for the formation of epithelium, but only a thick layer of 
granular substance. The fungi are therefore neither upon the epi- 
thelia, nor beneath them, but enclose them everywhere ; within 
the layers facing the mucous membrane, it no longer attains to the 
formation of complete basement epithelium, the thallus fibres, like 
the granular mass, seize upon them, and permeate them in every 
direction. 

As regards the primary place of origin, many authors assert 
that the primary white points represent mucous follicles, and that the 
fungi sprout from these. This statement can neither be confirmed 
nor denied, because it is well known that in the living child the ori- 
fices of these glands cannot be distinguished, and in the cadaver the 
presence of these thallus fibres in the follicles is no proof that they 
have actually originated there before they originated upon the free 
surface of the mucous membrane. 

As regards the spreading of thrush, Iteichold found that the fungi 
adhere to the pavement epithelium, and do not thrive upon the cil- 
iated and cylindrical epithelium ; consequently the parts subject to it 
are the mouth, fauces, oesophagus, and the epiglottis, down to the 
superior chordse vocales, by which the hoarseness which occasionally 
supervenes is readily explained. The tolerably wide-spread view en- 
tertained by older physicians, that thrush may extend down into the 
stomach and intestinal canal, has never yet been confirmed by dis- 
section. Although the possibility of thrush-membranes having been 



lOi DISEASES OF CHILDREN. 

swallowed, and subsequently passing off by the anus in an undigested 
condition, cannot be denied, it nevertheless does not follow therefrom 
that they had 07'iginated in the stomach and intestines. 

The duration of thrush, as a rule, is a short one, and in cleanly- 
kept and well-developed children very rarely lasts beyond the eighth 
day. In atrophic children, jDarticularly when their incessant restless- 
ness is appeased by the sugar-teat, it will last for many months, or 
until death. 

This affection of the mouth, especially in foundling and lying-in 
houses, is extraordinarily frequently complicated with intestinal catarrh 
of the most malignant character. This complication is so common 
that Valleix, physician to the Foundling-house at Paris, regards the 
intestinal affection as an integral part of the disease, and describes 
it as such ; but that is sufficiently contradicted by observations in 
private practice. 

Children are attacked by cholera-like symptoms, becoras collapsed, 
the anterior fontanel becomes depressed, the eyes sink back deeplv 
in their orbital cavities, the integument loses its elasticity and 
warmth, and, in from twelve to twenty-four hours, often become 
remarkably emaciated. The green, watery fteces, smelling strongly 
of rancid, sour fat, react decidedly acid ; redden and erode in a short 
time the anus, genitals, the inner surfaces of the thighs, and the 
heels. That this diarrhcea, or rather its effects, and not the affection 
of the movith, may lead to death, follows from this, that some chil- 
dren, with very severe thrush, suffer from no intestinal catarrh, and 
are perfectly well again immediately after the membranes have been 
cast off. 

The causes of thrush are, then : (1.) The preponderating acid re- 
action of the mouth, which in the new-born is due to a faulty salivary 
secretion. The quantity of the acid mucus outweighs the alkaline 
saliva, and then the mixture reacts acid. (2.) The transportation 
from one child to another, particularly through one and the same wet- 
nurse in foundling-houses. (3.) The almost unexceptionally ferment- 
ing substances of the sugar-teat, w^iich is sometimes allowed to lay 
about upon all dirty tables and places, and afterward is thrust into 
the mouth of the infant. 

Therapeutics. — From a large number of experiments which I have 
instituted in this direction, I have come to the conclusion that a thrush- 
membrane, when kept in sugar or well-water, and in a not-alkaline 
reacting solution of salt, at a temperature of about 110° F., will, 
at the expiration of two days, jDroduce a new crop of fungi, whereas in 
solutions of alkaline or metallic salts this does not take place. Thrush- 
membranes are effectually dissolved in concentrated solutions of caustic 



DISEASES OF THE DIGESTIVE APPARATUS. 105 

alkali only, which, of course, cannot be resorted to for therapeutic pur- 
poses. We have, therefore, no useful remedy that will chemically 
destroy the membranes in the mouth when once formed, but we can 
easily prevent their further spreading by topical applications of salts, 
with slight alkaline reaction. The whole treatment is based upon 
this : to rectify the acid reaction of the mouth, and this purpose is 
completely achieved by a solution of boras, 3 j, to water, 3 j, applied 
mth a small camel's-hair brush every hour. The good effects of tliis 
remedy, however, are often completely thwarted by the unnecessary 
admixture of honey or sjTup, for all substances which contain sugar 
very decidedly promote the growth of the fungi. By this solution 
of borax no diarrhoea is produced, nor is an already-existing one ag- 
gravated. It is absolutely necessary to discard the sugar-teat ; even 
a milk-diet is injurious, on account of its containing sugar and casein. 
So long as the membranes exist it is best to feed the child upon 
bouillon and mucilaginous broths, and infus. verbasc, with little or 
no sugar at all. 

APPENDIX. 

(a.) The Signification of a Coated Tongue in Children. — 
It is necessary, first of all, to state that most nurslings in the first 
weeks of hfe have a wliite-coated tongue, along with wliich they do 
not display the least digestive disturbance. 

Aside from that, the tongue becomes coated in most of the gastric 
and intestinal affections of small children, and probably only in con- 
sequence thereof does the appetite decrease. A thickly-furred tongue 
is but seldom met with in children ; as a rule, a white flush only is 
observed, but this may exist for a long time after the appetite has 
retiirned, and may just as w^ell be produced by local diseases of the 
mouth, thrush, stomatitis catarrhalis, diphtheria, injuries, chemical irri- 
tants, and burns, as by disease of the stomach or bowels. There are 
also permanent, or at least of several months' duration, partially- 
coated tongues, which possess no influence whatever upon the con- 
tinuation of good health. A special name has even been invented 
for this condition, p^7yJ•^as^s linguce. It consists of white islands, or cir- 
cles or semicircles, the rest of the tongue being of a normal rose-red 
tint ; these spots are entirely indebted for their origin to an accumula- 
tion of epithelium-cells. In atrophic children, transverse fissures are 
often seen upon a very smooth red tongue ; the fissures display yel- 
low bases, obstinately resist the cauterizing treatment, and do not dis- 
appear before death. Tlie furred tongue of measles, scarlatina, typhus 
fever, etc., has the same significance in older children as in adults 
and "\Aall be specially described with every individual affection. 



106 DISEASES OF CHILDREN. 

The diagnostic and practical importance of the coatings of the 
tongue in children is, on the whole, not j^articularly great. In a 
uniform, although but a very thin, coating of the tongue, it is al- 
ways advisable to be careful with the diet of the children, and, by regu- 
lating it, the digestion will improve, and the tongvie will become 
clean. 

(b.) Difficult Dentition {Dentitio Difficilis). — As the physi- 
ological condition of the eruption of the teeth has already been 
minutely treated of in the Introductory Remarks, it only remains 
to speak of the pathological conditions which originate during that 
process, and are decidedly dependent upon it. 

Redness, pain, swelling, and increased secretion (or, in short, catar- 
rhal stomatitis), are present in all cases. The frequent formation of blis- 
ters and small painful ulcers may be regarded as an aggravation of 
that process, and should be treated according to the precepts laid down 
on page 91 {Stomat. catar.). The necessity of the children to bite 
at something is satisfied by a piece of yew-tree root, or by a thimble 
firmly stuck upon the finger. 

As ordinary or sympathetic results of the eruption of the teeth, 
the following make themselves manifest : 

(1.) Fever, consisting in an increased temperature of the skin, 
especially on the forehead and cheeks, one of which often becomes 
red. Since no other cause for the fever can be discovered in the 
children, and as it nevertheless frequently occurs in dentition, it must 
therefore be assumed that it is induced by the latter. 

(3.) Cotwulsions — the so-called spasms [Fraisen). The convul- 
sions which occur here have nothing characteristic whatever, and are of 
the same nature as symptomatic convulsions in general. The most 
frequent muscular contractions are those of the eye ; teething children 
often sleep with half-closed eyes, the eye-bulbs rolled upward, and 
nothing but white sclerotica can be seen through the tolerably wide- 
open palpebral fissure, a phenomenon so terrifying to the inexperienced 
parents, that medical aid is usually quickly sought. Twitchings 
of the facial muscles, a peculiar smile while sleeping, and short 
twitchings of the extremities, are observed in many teething cliil- 
dren, who are extremely nervous, and attacked by reflex convulsions 
from the least indisposition — even from emotional causes. Since they 
make their appearance in many children every time a tooth breaks 
through, there is no reason why they should not be regarded as 
ha\'ing direct connection with the dentition. Still, eclamptic at- 
tacks occur in some children witli and without dentition, which may 
destroy them in a few minutes ; and at the autopsy no material lesion 
whatever of the nervous centres can be discovered. 



DISEASES OF THE DIGESTIVE APPARATUS. 107 

Treatment. — As these convulsions mainly occur in children with 
sluggish digestion and hard stools, and disappear when diarrhoea su- 
pervenes, the first indication must therefore be to increase the intestinal 
secretions and to accelerate the peristaltic movement of the bowels. 
A clyster or two of cold water should be administered to them, and, 
if this does not answer, a little manna, or a few teaspoonfuls of 
^ . rhei aquosa. But, if a hot skin is also present, it will be necessary 
to produce more frequent stools, and a diminution of the tempera- 
ture, which may be accomplished by a few powders of calomel, gr. -J 
to ^ each. Much eclat has lately been made in England and France 
with the scarification of the gums. Some recommend a crucial incis- 
ion ; others, the removal of the whole cap which covers the head of 
the tooth. But, as an admonition, it is premised, in all the reports and 
laudation, that the tooth has to be very near eruption, otherwise the 
scarification will be of no benefit. I have frequently performed this 
operation, but have always found that the lancinated wounds of an in- 
flamed mucous membrane heal very badly, and ulcerate for a long 
time ; that the nervous symptoms continue notwithstanding, till ulti- 
mately artificial or spontaneous diarrhoea supervenes. Indeed, if we 
have to wait until the tooth is " very near " breaking through, then the 
process is in fact near its end, and any other simple remedy is as effi- 
cacious as this, which is attended by a considerable amount of pain. 
Afiaisions of the head with cold water, performed every hour or two, 
are, it is true, a not very tender, and by parents not much admired, 
remedy ; it is, however, very useful against all convulsions in children, 
and therefore also against those occurring during dentition. 

(3.) Cutaneous Eru2)tions. — Children with a fine, smooth skin, or 
the progeny of parents who are affected with chronic skin-diseases, 
are attacked in each of the five periods of dentition by one or the 
other form of eruption, which, in the subsequent dentition periods, 
displays tolerably similar pathological characters to those which took 
place at their first appearance. The principal forms are : 

(a) Urticaria. — An eruption of wheals (Quaddeln) (Pomphi). — By 
this we understand a severely-itching eruption of the skin, of several 
lines in circumference and mostly round, or sometimes of an oblong 
shape, not very prominent, and having a flattened upper surface. 
Most of the wheal-like eruptions are of the normal integ-umentary 
color, while the part of the cutis contiguous to them appears to be 
reddened. Occasionally they are even paler than the rest of the skin ; 
the epidermis never becomes detached from the cutis. The stings of 
nettles (hence nettle-rash), in some persons also the bites of fleas, will 
produce a wheal-like eruption, which dififers in no respect from that 
produced by internal causes — dentition, for example. It disappears 



J08 DISEASES OF CHILDREN. 

almost entirely in a fcAV hours, tlie red zone remains for a short time, 
but that also fades very rapidly, and then nothing is to be seen of 
the eruption. From fifteen to twenty of these circular patches make 
their appearance, either simultaneously or one after the other, disap- 
pear, and are succeeded by others on other parts of the body. Gener- 
ally, this affection of the skin is relieved only after the completion of 
a dentition period, and breaks out anew at the beginning of the next 
period. The treatment should be limited to the use of bran-baths, and 
inunction of fat, to mitigate the excessive itching, which is very trouble- 
some and annoying. 

(b.) Lichen and Prurigo. — These are two papular exanthema; 
the first, also called lichen strophulus, has its hard papules mostly 
accumulated in clusters, while the papules of the latter are flatter, 
lower, and isolated. In both exanthema the tubercles are at first 
paler than the normal skin, but through scratching are soon bereft of 
their apices, and in place thereof display a small brown crust of the 
size of a pin's head. If a lichen papule is j^ricked open very super- 
ficially with a fine needle, a drop of blood will exude ; a prurigo papule 
contains onl}' a minute drop of serous fluid, but, by severe scratching, 
may also be made to bleed. When these scratched papules are situ- 
ated near each other, their crusts Avill coalesce, and present a large 
ulcerated surface, and it will then be entirely impossible to recognize 
the primary manner of their origin. 

(c.) Eczema and Impetigo. — By eczema, we understand an inflam- 
mation of the skin, produced by an accumulation of serum beneath the 
epidermis, in the form of minute aggregated vesicles, and is distin- 
guished as eczema simplex and eczema rubrum. In eczema simplex 
the skin is but slightly swollen and reddened. Thin yellow scales 
form after the vesicles have burst and dried up, and, after they have 
fallen ofi", a new epidermic layer is produced. Eczema rubrura mostly 
develops from the former, and is differentiated from it l)y the in- 
tegument around the vesicles being of a darker red color and more 
tumefied, and the course of the disease becoming more chronic. There 
is a tendency to form a new crop of vesicles, and a red, infiltrated fur- 
furaceous skin remains behind for a long time after the crusts have 
desquamated. In impetigo, in place of vesicles, larger pustules, filled 
Avith matter, usually aggregated, originate, and, after they have rup- 
tured, thick moist, yellowish-green or broAvn scales form, and, when 
these have dropped off, the reddened corium will be seen exposed, dis- 
charging a sero-purulent fluid, and soon becomes covered anew by a 
thick crust. The affected part of the skin remains brownish red and 
infiltrated for a long period after recovery has taken place. 

The forms of skin-disease mentioned in paragraphs b. and c. natu- 



DISEASES OF THE DIGESTIVE APPAEATUS. 109 

rally do not disappear immediately after the eruption of the teeth ; 
they improve very much, how^ever, while previous to that they con- 
stantly grew worse. It is not yet conclusively settled that they are 
always connected with dentition, for there are many children who do 
not acquire these eruptions until after they have cut all their teeth. 
But this much is established, that very many children are attacked 
by these exanthema, most frequently by lichen, at the eruption of the 
first tooth, suffer from it a while, lose it, and at the next new diffi- 
culties of dentition again become affected with it. 

The treatment of these skin-diseases is extremely simple. The 
hairs should be carefully removed, if any eruption exists beneath them. 
Thick crusts must be softened with oil, and the hairs cut off at the roots 
beneath the crusts, I have found the ung. zinci oxid., rubbed in tmce 
daily, to be very efficacious against the intense itching. So long as the 
patients are free from fever, they should be bathed in a tepid bath 
of wheat-bran for a quarter of an hour daily. There is no very 
great indication here for internal remedies, and those which derange 
the digestion should be avoided. In eczema rubrum, which often 
lasts very long, the liq. potas. arsenicalis, from two to five drops daily, 
may become necessary, in regard to the use of which, more minute 
details will be given in the chapter on the Diseases of the Skin. It 
is always advisable to cut off the nails as short as possible, of all 
children suffering from cutaneous eruptions, in order to make the 
scratching as harmless as possible. 

(4.) Intestinal Catarrh. — When a child cutting its teeth has a red 
mouth and augmented salivary secretion, it becomes affected with 
watery evacuations as a result of swallowing the saliva, for the salts 
it contains act as a mild aperient. A mild diarrhoea, five or six evac- 
uations in the twenty-four hours, is very beneficial to teething children, 
for cerebral affections are thereby most surely prevented. It occurs, 
in fact, as often as stomatitis catarrhalis, and both processes might 
very appropriately be regarded as physiological conditions, if their 
aggravations, which often attract attention, did not attain to distinct 
diseases, and really display serious characters. The transition of this 
simple catarrh of the bowels into an infiltration of the follicular ap- 
paratus of the mucous membrane, attended by profuse discharges and 
rapid general emaciation, very frequently occurs, and in most in- 
stances terminates in profound collapse and death. 

The treatment is precisely the same as that of intestinal catarrh 
originating from other causes, and Avill be described in detail with 
the affections of the bowels. 

(5.) Bronchial Catarrh. — There are children Avho, at the erup- 
tion of every tooth, are attacked by a severe bronchitis, which dis- 



110 DISEASES OF CHILDREX. 

appears again immediately after the tootli has broken through. This 
bronchitis seems to be induced by external causes. The large quan- 
tity of saliva secreted in stomatitis catarrhalis soaks through the 
clothes, covering the chest, and produces a diminution of the tempera- 
ture of the breast, as a result of which swelling and increased secre- 
tion of the bronchial mucous membrane ensue. If the chest is pre- 
vented from becoming wet, for example, by inserting a piece of oil-silk 
between the garments, the child will pass through the whole process 
of dentition without once being affected with bronchitis. So manv 
striking and oft-recurring examples of this dentition-bronchitis have 
occurred to me, that I do not hesitate to attribute a part of the bron- 
chial catarrhs to dentitio difficilis. 

Treatment. — The treatment consists in protecting the chest, best 
accomplished by employing large-sized slavering-bibs lined with thin 
gutta-percha cloth or oil-silk ; the cough then almost always disap- 
pears spontaneously in a very short time. 

(6.) Finally, there is a hlennorrhoic affection of the conjunctiva 
palpebrarum^ which occurs at the eruption of the upper cuspid and 
incisor teeth. Here both ej'elids, particularly the ujDper, suddenly 
swell up, and become so infiltrated that it is only with the utmost 
difficulty, and scarcely ever without bleeding from the squeezed 
eyelid, that a sight can be obtained of the globe. The disdiarge is 
not so yellow and purulently thick as in ophthalmia blennorrhoea 
neonatorum, but more muculent, shreddy, resembling more the dis- 
charge from the nose after a catarrh of the nasal mucous membrane 
has subsided. I have never been able to ascertain whether it pos- 
sesses any properties of infecting the other eye of the same or of 
another person. The parts around the lids are generally eroded. On 
examining the mouth of a child laboring under this form of inflamma- 
tion of the eye, a painful redness and swelling of the corresponding 
irpper jaw, and one or two tubercles answering to the first molar or 
incisor-tooth, will be found ; its popular denomination, " eye-tooth," is 
therefore not without sufficient reason. 

After all, this inflammation of the eye has nothing wonderful 
about it, when we bear in mind that the floor of the Highmorrian 
cavity is often barely of the thickness of paper, and consequently a 
projiagation of the congestion or inflammation upon the mucous mem- 
brane of this cavity may very readily take place. But the mucous 
membrane of the antrum Highmorri stands in direct communication 
with the conjunctiva through the nasal passages and lachr^ymal sac, 
and we merely have here a propagated inflammation of the mucous 
membrane. The prognosis of this seemingly very dangerous e\-il is 
favorable. Formerly, in accordance with the precepts of the most 



DISEASES OF THE DIGESTIVE APPARATUS. m 

eminent ophthalmologists, I used to torture the poor children with 
cauterizations of nitrate of silver, and was delighted vnth. my 
splendid success. But, for several years past, I have treated at least 
a dozen cases with nothing but dry warmth, discarding the cauteriza- 
tions altogether, and have accomplished still more rapid and painless 
cures. I apply a piece of cotton-cloth to the eye, smeared with 
simple cerate or ung. zinci, and over that a bag loosely filled with 
warm bran. I cause the cerate rag to be removed every two hours, 
the eye to be sponged with a pointed piece of soft sponge dipped in 
warm water, and then reapply the warm bran bag as before. After 
one, or at the most two days, the oedema has subsided so much that 
the patients are again able to open the eyes tolerably wide ; then 
they will no longer tolerate the bran bags, and, after several days 
more, there is nothing more to be seen about the affected eye than a 
slight redness and irritability of the lids. If the mouth is now ex- 
amined, the stomatitis will be found improved or wholly gone, and a 
previously unperceived head of a tooth cut through. During and 
after the subsidence of the oedema of the lids, mild astringent eye- 
washes, zinci sulph., or cupri sulph., gr. j, to water 3 j, may be 
dropped into the eye with advantage. 

These are the principal and most frequent complications of denti- 
tion ; their actual dependence upon it has long ago been acknowledged 
by all thoughtful physicians. Of late, however, a few, and some of 
them widely-known Psediatricars, have denied this connection in toto, 
and either did not observe the frequent concomitance of the just de- 
scribed diseases with dentition, or declared them to be merely acci- 
dental. 

According to Israeli^oi Amsterdam, who has compiled the death- 
rate among children in that city for the last thirty years, the maxi- 
inum of mortality occurs naturally enough in the first month of 
infantile life. From that time on it decreases considerably, and 
reaches its second maximum between the third and fourth months 
of life. In the fifth and sixth it again decreases to one-third of the 
former months, in order to reach its third maximum in the seventh 
and eighth months. In these months the mortality is three to four 
times as great as in the preceding. In the ninth and tenth it again 
diminishes, and in the eleventh and twelfth it sinks to a minimum 
of the first year of life. Now, as the process of dentition is in 
full operation in the seventh and eighth months of infantile life, 
it is perfectly natural to connect the greater mortality with this 
process. 



112 DISEASES OF CHILDREX. 



B.—PAROTIS. 



Hypekteophy of the Parotid Gland. — There is («) a benign 
and {b) a malignant hypertrophy of the parotid gland. 

(a.) The benign form may originate slowly and spontaneously, 
but is oftener the result of the above-described inflammatory con- 
ditions. Occasionally benign, fibroids, adipose, or cystic tumors, 
also develop themselves in the gland. The integument over the 
benign tumors is always displaceable. Simple hypertrophies are 
always unilateral, the pain on pressing the gland is very slight ; 
the lower jaw is therefore always sufficiently movable, even in 
tolerably large swellings. It is differentiated from scrofulous in- 
duration of the cervical glands by the lobe of the ear not being 
pushed off here ; the glands are more movable, and generally found 
in large numbers. 

Treatment. — Sim2Dle hypertrophies may be made to diminish in size, 
or to disai:)pear altogether, by an external application of iodine, once 
or twice a week, continued for some time ; benign lijDoma, and other 
tumors in the parenchyma of the gland, of course, do not disappear 
under the use of iodine ; they must be removed by the knife, whenever 
they are sufficiently superficial, and it is possible to enucleate them 
without too great vascular and nervous injury. 

(h.) IMalignant hypertrophy of the parotid consists in the exubera- 
tion of a medullar}- or fibroid carcinoma in the parenchyma of the gland. 
It, however, never occurs primarily and isolated in the parotid ; in most 
instances, it appears with a simultaneous carcinomatous deposit in 
other organs, and, as carcinoma in general, is extraordinarily rare in 
children. Where the carcinoma attains to a considerable growth in- 
wardly, pressure upon the pharynx and larynx, and upon the large 
vessels and nerves of the neck, may ensue. The tumor also grows 
anteriorly, occasionally over the ascending ramus of the lower jaw, 
the contour of which then becomes indefinable. It is almost Avholly 
immovable, and, according to the nature of the heteromorphous 
growth, hard (in fibrous carcinoma), or soft, even fluctuating (in me- 
dullary carcinoma). 

The inteo^ument in the first kind is immovable, having^ become 
identified with the hard tumor. Tuberculous infiltration scarcely ever 
occurs in the parotid. 

The treatment is as for carcinoma in general, merely life-prolong- 
ing. I am unable to say whether by extirpation of the carcinomatous 
parotid, one of the most dangerous and difficult operations in surgery, 
a child has ever been saved. 



DISEASES OF THE DIGESTIVE APPARATUS. II3 

G.—PHABTA'X AJSTD (ESOPHAGUS. 

(1.) Angixa Tonsillaris. Cynanche (literally the "dog's col- 
lar," from Kvuv., the dog, and a/j^^ew, to strangle). — The tonsils are ag- 
gregated mucous follicles, which in the normal condition ought to 
project barely above the arches of the palate, between which they 
lie. On the surface facing the isthmus faucium ten to twenty excre- 
tory ducts of mucous crypts are found, which give to the tonsils a 
perforated appearance, similar to that of the shell of an almond. 
Now, these ten or twenty crypts of each tonsil are subject to inflam- 
mation and suppuration, in which, like the furuncles of the cutis, the 
contents of one or several follicles induce suppuration of their sur- 
rounding textures, and finally are discharged by an opening that forms 
in the abscess. In this process, the whole parenchyma of the tonsil 
swells up, and is much disposed to pass over into a state of chronic 
induration ; the latter condition may also originate spontaneously 
^vithout having been preceded by suppm-ation of the crypts, and it 
then will be bilateral. A hollow, depressed excavation remains be- 
hind after each suppurative process, so that when the malady has 
recvirred often the tonsils appear torn and ragged, but are thereby 
greatly reduced in size. The oftener angina tonsillaris has occurred, 
all the more probable is it that all the follicles have been destroyed, 
and all further opportunities for future inflammations have thereby 
been abolished ; a rare example of a radical cure by Nature herself. 

Symptoms. — The disease begins with difficult deglutition, pain, 
heat, and dryness of the throat. The afi'ected tonsil becomes uni- 
formly enlarged, and may be felt externally beneath the lower jaw as 
a small tumor. If both swell up simultaneously, as happens very 
often, they will touch each other; and all the symptoms become 
greatly aggravated, till finally even sufibcation may ensue. Here the 
voice always becomes snuiSing ; the pain radiates toward the ear ; as 
a result of the upward pressure of the posterior pillar, the jDassage 
leading to the pharyngeal opening of the Eustachian tube may become 
mechanically closed, and in this manner tinnitus aurium and hard- 
ness of hearing may be produced. The pain is greater on swallowing 
fluids than solids, such as bread and meat, for these, by their solidity, 
bore their way through, Avhile fluids can only be forced through by 
the uniform pressure of the whole mouth against the swollen tonsils. 

In examining the mouth, some precautions are to be exercised ; the 
patients should be placed opposite a bright -window, and at first simply 
be ordered to open the mouth, by which the entire process is often 
readily seen, especially if, at the same time, they put out the tongue 
and take a deep inspiration. If it is not possible in this manner to obtain 



114 DISEASES OF CHILDREN. 

a good view of the tonsils, the tongue will have to be depressed ; and to 
this, according to my experience, the children submit themseves more 
readily when it is done with the finger than spatula or spoon-handle. 
Moreover, the tongue can be depressed much deeper with the finger 
than with the spoon-handle, and the head can also be more readily fixed. 
The soft palate is now seen to be reddened and the highly-inflamed 
tonsils covered with thick tenacious mucus. They fill up the greater 
part of the isthmus faucium. When the angina has existed for a 
couple of days, a few yellow dots will be observed on the tonsils, 
which, on puncture, emit a considerable quantity of fetid pus, and after 
a few days recovery is established, so far, at least, as the objective 
symptoms are concerned ; for, notwithstanding the loss of substance, 
such a tonsil remains enlarged for years. Acute angina tonsillaris, 
with pain, difficult deglutition, and fever, in children, seldom lasts 
longer than five or six days, then the abscess bursts, or, if it does not 
attain to suppuration, it will pass over into the chronic, painless in- 
duration. 

As regards its etiology, the disease sometimes occurs in an epi- 
demic form; generally, however, the cases are only sporadic, and 
occur in particular!}- predisposed individuals. Aside from this, inflam- 
mation of the tonsils is a constant attendant upon scarlatina ; here, 
however, it does not usually pass over into the suppurative state. It 
is also sometimes met with in secondary syphilis, which, on the whole, 
manifests itself on the soft palate and tonsils more rarely in children 
than in adults. 

Therapeutics. — The treatment varies according to the age of the 
child. Small children under three or four years, who are less liable to 
this disease than those in whom the permanent teeth have appeared, 
are, it is well known, unable to gargle, and never retain water in the 
mouth, but swallow it directly. Thus, one of the principal palliative 
measures cannot be employed in these cases. The very popular eibis 
gargles mitigate the pain less and cannot remove the mucus that con- 
stantly coats the tonsils and fauces as well as cold water, which the 
patients shovild be induced to hold in their mouths, not gargle, till it be- 
comes disagreeable to them by its own warmth ; it is then replaced by 
fresh water. Thick cataplasms and bran-bags, in which half of the heads 
of patients are generally wrapped up, are said to accelerate suppura- 
tion, but they certainly make the head hot and discommode the child. 
I am more convinced that they produce the latter efi"ects than the 
former, and for that reason do not employ them. Rubbing the neck 
with oil soothes the pain, and does not heat the skin. In adults se- 
vere anginous troubles may be mitigated very rapidly by a few leeches ; 
in children, however, the loss of blood, and apprehension and excite* 



DISEASES OF THE DIGESTIVE APPARATUS. n^ 

ment attendant upon the application of leeches, deserve more con- 
sideration. Incisions into the intensely-swollen tonsils, with which, 
in adults, gi-eat mitigation and abortion of the pain may be effected, 
require, first of all, the consent of those to be operated upon, which is 
useless to hope for in children. But where the dyspnoea is very great, 
and suffocation imminent, they have to be made, and cannot be re- 
placed by the repeated use of tartar emetic. We succeed very rarely 
in causing the abscess to burst through retching. In that case, at any 
rate, the matter must have been very superficial, and in all probability 
would have been spontaneously evacuated in the next few hours. 

In acute angina tonsillaris we may limit ourselves, therefore, to 
gargles of cold water and inunctions of oil. If suffocation threatens, 
incisions must be made into the tonsils, and when, owing to the great 
restlessness of the child, and for want of proper assistance, these cannot 
be safely performed, then an emetic may be tried. The constipation 
that is usually present is very appropriately relieved by a mild laxa- 
tive such as decoct, tamarind, inf. rhei, or by a few teaspoonfuls of IJ . 
rhei aquosa. 

(2.) Htperteophia Tonsillarum. — There is an hereditary hyper- 
trophy of both tonsils which develops very early in life, often in the 
second year, and is not the effect of anginse. Here both tonsils are 
equally swollen, push the soft palate forward, lock the uvula in be- 
tween them, enlarge upward toward the posterior nares, and thereby 
produce a snuffling voice. Occlusion of the mouth of the Eustachian 
tube induces tinnitus aurium and hardness of hearing. No redness, 
pain, or subjective symptoms, are present here ; the dyscophosis, the 
snuffling voice, the keeping open of the mouth both night and day, a 
perpetual snoring during sleep, are the main signs that induce us to 
examine the tonsils, which are then found decidedly enlarged, and may 
also be felt from without. 

I never observed atrophy of the respiratory muscles, and that pe- 
culiarly-shaped breast, pectus carinatum (pigeon-breast), first stated 
by Dupuytren to be the effects of hypertrophied tonsils, or, at least, 
they did not seem to be such frequent concomitants of this condi- 
tion that an actual relative dependence might be deduced therefrom. 
There are a number of very-well-develojDcd children Avho do not show 
the least trace of a pigeon-breast, or the least affection of the chest and 
thoracic viscera whatever, and yet suffer from hypertrophied tonsils ; 
and again a still greater number of children, notwithstanding perfectly 
normal tonsils, are afflicted with a very severe degree of pigeon-breast 
and imperfect development of the pectoral muscles. 

Before the commencement of puberty an arrest in the growth of 
the hypertrophied tonsils takes place, and in the adult the free space 



116 DISEASES OF CHILDREN". 

between them becomes enlarged. Children afflicted with this com- 
plaint are liable to acute anginous affections, and it is often accom- 
panied by diseases of the skin, eyes, and bones. 

Treatment. — The milder forms require no treatment at all. I have 
seen a remarkable diminution of the hj^ertrophied tonsils under the 
use of cod-liver oil for several months, given for other scrofulous com- 
plaints, but in the severest grades of the evil this remedy failed 
entirely. By cauterizations with nitrate of silver, skilfully performed, 
so as to give the children no pain or embarrassment, twice weeklj^ and 
continued for a long time, a tolerable diminution in the size of the 
tonsils will be obtained, and in many instances the children, or rather 
their relations, Avill thereby be spared an operation. But where the 
evil is of a very serious degree, extirpation of the gland is absolutely 
called for ; as otherwise the children may perish by suffocation. The 
operation is best performed with MathieiCs tonsillotom, with which the 
gland is first transfixed and then abscised. Children who are taken 
by surprise, and have no presentiment of an operation, willingly allow 
their tonsils to be embraced in the instrument, and in the next moment 
the glands are cut off, the patient hardly being aware of what has 
hapj^ened. The removal of one tonsil suffices to open the isthmus 
faucium; sometimes the operation may be performed immediately 
afterward on the other side ; usually, however, the child resists it, and 
it is not advisable to use chloroform, as the blood from the severed 
tonsil may flow dovm into the air-passages. 

The wound should be allowed to heal, and the other tonsil is cut off 
some other time, if the symptoms are not sufficiently mitigated bj^ the 
first operation. The amputation of the gland by the aid of 3Iussex''s 
forcej^s and knife is very laborious, and also very dangerous, on account 
of the close proximity of the internal carotid, which internally and 
behind is in relation with the tonsil, for in restless children it is lia- 
ble to be injured. 

(3.) Retropharyngeal Abscesses. — According to JBokai, ab- 
scesses of the posterior wall of the pharynx may be divided, in respect to 
the manner of their origin, into three kinds : (a), into such as develop 
themselves idiopathically from an inflammation of the pharynx and of 
the cellular tissue surrounding it ; (J), into such as form secondarily, 
the result of supjxiration of inflamed cervical glands ; and (c), into such 
as are complicated with caries of the cervical vertebrae. 

In all the three forms the first symptom is always a slowly-in- 
creasing pain on swallowing, to which a certain amount of stiffness of 
the neck, in the motions of the head without any externally percepti- 
ble diseased condition of tliis part, soon becomes superadded. The 
voice assumes a snuffling tone, and, on examining the mouth, the pha- 



DISEASES OF THE DIGESTIVE APPARATUS. n^j 

ryngeal space is found constricted, the posterior wall of the pharynx 
not equidistant on both sides from the soft palate, and of a livid color. 
As the disease advances, the stifihess constantly grows more marked, 
the head is bent backward, and dyspnoea appears whenever the chin is 
made to approximate the sternum. The neck in the region of the an- 
gle of the lower jaw becomes slightly thicker. Fever and restlessness 
supervene, and increase from day to day with the growth of the al> 
scess. In the highest grade of this evil children are totally unable to 
swallow, breathe very laboriously, with painfully-distorted features, 
the respirations are loud, stertorous, but not whistling, as in croup, for 
which, at first sight, the disease might be mistaken, especially since 
here, too, the speech becomes indistinct and the voice tuneless. The 
mouth is constantly full of mucus, and finally the posterior pharyngeal 
wall, on touching, fluctuates tolerably distinctly. The abscess may 
attain to such a size as to get in front of the soft palate, which will 
appear to he upon it. When it extends deeply downward, even the 
OS hyoid and larjmx will be pushed forward or to one side, and, when 
at last it is o]3ened, a large quantity of matter v^dll flow out with a 
gush, followed by an instantaneous remission of all the phenomena ; 
spontaneous bursting of the abscess during sleep is said to have 
caused death by sufibcation, the pus filling up the larynx. 

In the second form, following upon suppuration of the cervical 
glands, enlarged or suppurating lymphatics will in addition be found 
on the neck ; and in the third, the most frequent kind, the preceding 
signs of disease of the cervical vertebrae for many months, such as 
pain and difficulty on rotating and bending the head backward, draw- 
ing upward of the shoulders, and hypertrophy or alterations in form of 
the affected vertebrae, may be observed. Although suppuration of the 
cervical lymphatics belongs to the common diseases of childhood, still 
retropharyngeal abscesses, resulting from this affection, are of extreme 
rarity. I have never yet met with this sequela of suppuration of the 
lymphatic glands. The prognosis in retropharyngeal abscesses is 
always doubtful ; when they are accompanied by caries of the verte- 
brae, it is almost always of the fatal issue. 

Treatment. — Since the diagnosis cannot be established with cer- 
tainty till after the abscess has formed, but little can therefore be ex- 
pected from antiphlogistics, leeches, ice, and laxatives, still less from 
resolvents, blue and iodine ointment, tincture of iodine, and cata- 
plasms. 

Patients a few years old derive the greatest relief from pieces of 
ice in the mouth, as it exercises an astringent and local anaesthetic 
influence. But when the physician has convinced himself of the ex- 
istence of an abscess, an early opening is the only means whereby the 
9 



118 DISEASES OF CHILDREN. 

harassing symptoms can be removed. When disease of the vertebral 
column is at the same time present, which, after all, is not very easy 
to diagnosticate, JBaniberger justly advises to defer the operation until 
actual danger threatens, for the superaddition of air always accelerates 
the progress of the carious destruction of the vertebrae. If any im- 
provement in caries of the cervical vertebras is expected to ensue, then 
constant quiet rest in bed upon the back for several months is indis- 
pensably necessary. Conjointly wdth this, of course, the strength is to 
be supported in every manner possible, and subsequently the attempt 
must be made to cause absorption of the hypertrophied tissues of the 
vertebrae by the insertion of a seton, as well as by a long-continued 
use of iodide of iron. 

(4.) Inflammation of the OEsophagtjs ( (Esophagitis). — Al- 
most all the affections of the mucous membrane of the mouth may 
extend down upon the mucous membrane of the oesophagus to the 
cardiac orifice of the stomach. Thus there is a catarrhal, mercurial, 
and diphtheritic inflammation of the same. Thrush also may extend 
down to the stomach. The most frequent form of disease of the 
oesophagus, however, is that produced by corrosive substances and 
foreign bodies. It scarcely ever occurs in children under one year of 
age, because these are still too simply fed, and are not apt to catch 
injurious articles and swallow them. 

The sjinptoms of oesophagitis are as follows: Burning or lanci- 
nating pain at some part of the oesophagus, in the neck, in the back, 
between the scapulae, or in the praecordia. Deglutition is always at- 
tended by pain ; even the blandest fluid, the saliva itself, does not 
pass down without pain. Retching or actual vomiting \W11 take place 
according to the severity of the pain ; deglutition is particularly em- 
barrassed in the dorsal decubitus, for, when the head is tlirown far back- 
ward, the anterior wall of the cervical column forms a convexity which 
protrudes into the fauces ; on this account it is customary to raise the 
head of a child whenever any thing is administered to it. The thirst in 
oesophagitis is very tormenting, but, for fear of the pain, children will 
refuse all drinks for days. Since the most common causes of oesopha- 
gitis are scaldings with hot water, lye, and concentrated acids, the 
principal morbid lesions are therefore always found in the mouth, and 
from these a conclusion may be arrived at as to the condition of the 
mucous membrane of the oesophagus. If ulcers have formed, they will 
heal but very slowly, for the oesopl^agus is stretched and distended 
every time any thing is swallowed, and strictures Avill almost always 
be the result ; these slowly grow worse, the cahbre of the tube, after 
many months, becomes contracted, and constantly grows narrower. 
Besides this oesophagitis from burns, which mainly originates through 



DISEASES OF THE DIGESTIVE APPARATUS. HQ 

the ignorance or clumsiness of children, who, instead of instantly spit- 
ting out again the corrosive fluids, swallow them, there is yet an 
oesophagitis of traumatic origin. It is produced by swallowing cer- 
tain articles, such as fish-bones, fragments of meat-bone, needles, and 
by sharp bodies of all kinds which remain sticking in the gullet, and 
clumsy and rough attempts to remove them. Finally, ulcers of the 
oesophagus have also been met with as a result of the administration 
of large doses of tartar emetic, in powder. 

Treatment. — All attempts to remove foreign bodies are attended 
by the greatest uncertainty, since it is impossible to arrive at any 
exact knowledge of the place of fixture and the character of the ex- 
traneous substance. Nor are they always necessary ; for there are a 
number of articles, such as crusts of bread, hard cake of all kinds, 
even bits of wood, which, if allowed to remain for some time, become 
soft, and are subsequently carried down by some swallowed fluid. 
The longer the foreign body has remained, the more difficult it will 
be to remove it, because the inflammation of the oesophagus constricts 
its cahbre. The attempt to push down sharp objects into the stomach 
may terminate disastrously, for it is just as easy to push them through 
the coats of the oesophagus as into the stomach. If the foreign article 
does not completely fill up the calibre of the gullet, as is scarcely ever 
the case with sharp or angular objects, it may sometimes be removed 
by an instrument let down over it, at the end of which there are a few 
blunt hooks, or by one that may be made to unfold after the manner 
of an umbrella. 

Against chemical bums, if they are of but very recent occurrence, 
antidotes — acids against alkahes, and vice versa — must be administered 
properly diluted. Subsequently emulsions are to be given, and, to 
palliate the thirst, bits of ice are allowed to be melted in the mouth, 
if the child obstinately refuses to swallow. It will scarcely be neces- 
sary to prohibit the partaking of solid nutriments, as the mere attempt 
causes intense pain. If the pain is very severe, warm-water com- 
presses should be applied to the neck, and opium given according to 
the age of the child : to a child two years old, one drop of laudanum ; 
to one of three years, two drops, and so on, one drop more for every 
additional year. A very disagreeable and frequent termination of 
ulcerations of the oesophagus, such as result from chemical or me- 
chanical irritants, are strictm-es, which must be prevented by the pas- 
sage of bouo-ies, after the manner of strictures of the vu-ethra. Where 
they already exist, the frequent use of the bougie is the only means 
of saving the patient from starvation. 

(5.) CoNGEMiTAL FisTTTLA OP THE Neck [Fistula ColU Congen- 
ita). — A very rare, imperfectly-described, almost problematical dis- 



120 DISEASES OF CHILDREN. 

ease. I have never had an opportunity to see it. According to 
JBednai\ it is indebted for its origin to the second or third gill-fissure 
remaining open. According to the same author, its external opening, 
in the environs of which the integmnent is firmly adherent to the 
subcutaneous cellular tissue, and forms a depression, is foimd in the 
lateral region of the neck, at a distance of half an inch from the 
clavicle and its junction with the sternum. Its internal opening 
either terminates in the head of the oesophagus, near the epiglottis, 
or in a cul-de-sac near it. The secretion of this fistula is a thick, 
tenacious mucus, and is discharged mainly during mastication and 
deglutition ; water injected into it excites acts of deglutition. 

All attempts to cure this deformity by means of cauterization have 
hitherto proved fruitless. 

(6.) Sclerosis of the Stee:n'o-cleido-mastoideus Muscle. — 
In the first weeks of life a peculiar, cord-like thickening of one of the 
sterno-cleido-mastoid muscles occasionally occurs, the pathology of 
which is as yet by no means clear. The induration is evidently situ- 
ated in the muscle, not over or near it, ahvaj-s occurs unilaterally, has 
a cylindrical, lead-pencil-like form, and is from one-half to an inch in 
length. In most instances the tumor is tolerably movable, becomes 
more marked during the pressure of the abdominal muscles upward 
(during the act of inspiration), and participates in all the movements 
of the muscle. Paget states that the face cannot be turned toward 
the affected side ; in the three cases that have so far occurred to me, 
no perceptible functional disturbance of the muscle was noticeable. 
The etiology, as given by the French writers, who regard the indu- 
ration as having simply originated from a difficult labor, the use of 
forceps, etc., is not applicable to my cases, for the delivery in all 
three cases took place without any assistance from art, and the tumor 
was not noticeable till a few days after birth. The supposition of its 
being a tumefied Ij'mphatic gland is untenable, on account of its 
cylindrical shape, and the absence of glandular indurations in other 
parts of the body. 

Treatment. — AU authors, Lahalbary, Melchiori^ Dolheau, Paget^ 
Wllks^ etc., unanimously agree that the tumor disappears entirely 
after a few weeks, under the external use of iodine, and this I am 
fully able to confirm from my own experience. 

Tt.-STOMACE AND INTESTIXAL CANAL. 

(1.) The most Impoeta]!jt Symptoms of Gastkic ^^^d Ii^estkcal 
Affections. — So many symptoms repeat themselves in the various 
diseases of the stomach and bowels, that it seems judicious to be- 



DISEASES OF THE DIGESTIVE APPARATUS. ^21 

come thoroughly conversant with them before entering into a de- 
scription of the individual diseases, which may then be studied more 
comprehensibly in an anatomo-pathological manner. 

(a.) Dyspepsia (from dvgivsipia, difficult digestion). — By dyspep- 
sia is meant a complete abolition or merely a diminution of the appe- 
tite; in the latter case the ordinary articles of food are despised, 
and the patient has only a desire for delicacies, of which, however, 
he consumes but very little. The appetite is the most authentic 
index to judge a general disease by, and the examination that has to 
be instituted in reference thereto embraces the most important and 
difficult part of the whole examination of the patient. The physician 
should never be satisfied with answers embracing general amounts, 
but should ascertain very accurately the quality and quantity of 
the nourishment consumed, should have the dishes shown him out 
of which the child is fed, see how much they contained before the 
meal, and how much remained, etc., for then only can a correct 
impression be obtained of the actual or imaginary decrease of the 
appetite. 

Bamberger, in his work on the Diseases of the Chylopoetic System, 
treats of the following four kinds of dyspepsia : 

(1.) Dyspepsia from pathological alterations of the digestive 
organs. 

(2.) Dyspepsia from quantitative and qualitative anomalies of the 
digestive secretion. 

(3.) Dyspepsia from altered nervous influence, to which also the 
secondary digestive disturbances occurring in the various diseases 
belong ; and, 

(4.) Dyspepsia from abnormal irritation of the nutriments. 

All these forms of dyspepsia occur in children just as in the adult. 
The first is the rarest ; the second is very frequent, and accompanies 
principally the augmented evacuations from the intestinal canal, 
diarrhoea. The third is present in all acute febrile diseases, and sup- 
plies the best cardinal point in judging of the severity and duration 
of the fever, and the fourth is the most frequent disease in the whole 
Pffidiatrica, from which the majority of artificially-fed children suffer 
the whole of the first year of life. That these different kinds cannot 
always be strictly distinguished from each other needs scarcely to be 
expressly stated, since, indeed, some are directly dependent upon 
and stand in the closest connection with each other. 

In every dyspepsia the act of digestion is not only retarded, but 
also accompanied by numerous local and general difficulties. The un- 
digested articles of food that have been lying in the stomach for some 
time constantly generate gases, which have a smell, alUed, though 



122 DISEASES OF CHILDREN 

only slightly, to some of the substances consumed, and which is to be 
distinguished from the odorless air that has simply found its way into 
the stomach by swallowing. The greater part of the gas first devel- 
ops itself in the alimentary canal and distends it, by which pains are 
produced on touching the abdomen, or moving the body, which, as a 
rule, terminate with the discharge of a large quantity of flatus. Some 
children, suffering from disturbed digestion, complain also of a feeling 
of pressure, of fulness and pain in the praecordia, and a consecutive 
frontal or parietal pain almost invariably becomes superadded, which 
does not disappear until the appetite has returned. The usual 
and rapid termination of every dyspepsia, particularly if it is only 
caused by abnormal irritation of the food, is vomiting, after which 
the appetite returns, and the consecutive symjDtoms quickly disappear 
also. 

Therapeutics. — The treatment of dyspepsia calls for a thorough ex- 
amination into its causes, and, according to these, is sometimes radi- 
cal, sometimes symptomatic, and then again merely expectant. The 
circumstances are often so complicated, the causes so difficult to 
fathom, that it is one of the severest tasks to establish general rational 
rules for it. The whole basis of treatment depends upon strict diet, or 
the deprivation of food, as rest in general, and of the diseased organs 
in particular, forms the first principle of therapeutics. Let the cause 
of dyspepsia be what it "vvill, its effect is always the same — diminution 
or total abolition of the digestive ability — and the introduction of 
liquid, and, still worse, solid nutriments, is, therefore, under all cir- 
cvmistances, injurious. Where pathological alterations of the digest- 
ive organs exist, there, of course, no impression will be made upon the 
anorexia with any remedies, since it is only a result of the disease 
of the mucous membrane, and will persist as long as that condition 
does not assume a curative process. Dyspepsia caused by anomalies 
of the digestive secretions may often be quickly reHeved by properly- 
selected remedies. It often happens, especially in artificially-fed chil- 
dren, as a result of the numerous articles of food which are not yet 
adapted to the infantile stomach, that a much more acid gastric juice 
is secreted than in those at the breast, and even when the diet has 
been regulated for a long time, so as to correspond with the age of the 
infant, this secretion still continues to be poured out in large quan- 
tities, causing dyspepsia and vomiting. This condition was known in 
the oldest times, and oculi cancrorum was prescribed for it, which, 
with justice, has been supplanted by carbonate of lime, of magnesia, 
or of soda. Which of these three remedies should be selected is 
almost wholly immaterial ; they all neutralize the profuse, super-acid 
gastric juice in the same manner, and when a child has taken one or 



DISEASES OF THE DIGESTIVE APPARATUS. 123 

several grains of either of these remedies, for a few days, its appetite 
and digestion will be improved, provided the presumption of the 
cause was correct. 

Some children are tolerably often attacked by icterus, and in the 
first few days suffer from complete anorexia. In many instances 
I have seen this disappear at once under the use of argent, nitr,, which 
in children five years old may very appropriately be given in pill form, 
each pill containing one-sixth of a grain of the salt. After three or 
four pills the appetite will become reestablished, although the icterus 
will remain for some weeks. 

Dyspepsia which accompanies febrile diseases requires no special 
treatment ; the instinct in children is still more potent and correct than 
in adults. Children with a really hot and dry skin and accelerated pulse 
do not touch the food that is placed before them, nor do they readily 
drink any nitrogenous fluids, such as milk or soups, but always call for 
cold water, and prefer it to sweetened and acidulous drinks. There 
is no remedy for this form of dyspepsia, and, even if there were, its use 
would undoubtedly be contraindicated during the duration of the fever. 
On the other hand, it frequently happens that by the too assiduous 
administration of remedies, such as tart, emeticus, in small doses, ipe- 
cacuanha, neutral salts, acids, etc., the digestion of children is inter- 
fered with and retarded longer than the fever would last, and the 
convalescence is thereby delayed. 

In dyspepsia caused by abnormal irritation of the nutriments, the 
child is to be kept upon a strict diet for several days — nothing but 
mucilaginous broths, or milk mixed with chamomile-tea, should be 
given ; afterward the child may be fed in the manner prescribed on 
pages 43 to 46. Calomel, in one-eighth-grain doses, given two or three 
times daily, exercises an extremely beneficial effect upon such an irri- 
table mucous membrane; it produces a few green evacuations, the 
tympanitic, distended abdomen becomes smaller, rest and sleep follow, 
and the child begins to digest again. 

(b.) JBulhnia (from fiovXc/nia, ravenous himger). Polyphagia 
(from 'Kolvj)ayia, greediness). Fames Ganina. — A morbid increase 
of the appetite may, it is true, also be acquired through bad habits and 
a depraved rearing, but in children it is oftener a symptom of various 
morbid conditions, above all, of intestinal worms, next of hypertrophy 
of the mesenteric glands, and of chronic cerebral affections. The rav- 
enous hunger coming on after acute diseases, particularly typhus fever, 
does not belong here, it finds its physiological explanation in the rapid 
replacement of the adipose tissues that have been lost. So also of that 
bulimia which originates in general good health, and without any dis- 
ease of the organs, must an especial disposition be assumed ; for, although 



124: DISEASES OF CHILDREN. 

very many children are constantly urged by their irrational parents 
to eat, and incessantly stimulated thereto by a change of delicacies, 
still few are able to acquire this rare condition. In these cases, the 
objects with which children seek to appease their ravenous hunger 
always belong to the class of delicate nutriments, but depraved 
longings, depending upon morbid alterations of the organs, also occur 
in greediness similar to that in pregnant women. Such children eat 
raw and bad victuals, and roots of all kinds, and refuse at no time of 
the day, not even directly after a meal, a slice of rye bread, of which 
they will consume as much as they can obtain. "WTien this condition 
cannot be remedied sufficiently early, it becomes chronic, without the 
children increasing thereby in size and weight faster than those who 
are more moderate. On the contrary, they generally look pale and 
angemic, have frequent evacuations, putrid-smelling stools, and are 
retarded in growth. At the autopsy, an extraordinarily large stomach, 
with thickened walls, and those morbid alterations already mentioned, 
are usually found. 

Therapeutics. — The treatment is successful and rapid, if intestinal 
worms which may be expelled by the various anthelmintics are the 
cause of the polyphagia ; but unsuccessful if, as in atrophic children, 
the mesenteric glands are collectively hypertrophied and infiltrated, or 
when a chronic hydrocephalus is the cause of the bulimia. Here we 
have to limit our efforts to supplying at least easily-digestible, bland 
nutriments ; it will scarcely ever be possible to diminish them in 
quantity. 

(c) Vomiting (Vomitus). — Vomiting has frequently a diflferent 
signification in children from that in adults. A great number of in- 
fants, as often as they have been nursed, throw up the greater part 
of the milk without any retching, without any distortion of the 
features, and without any consequences ; this occurs all the more 
readily if they have been moved about or dandled up and down after 
nursing. This vomiting is very much facilitated in children by the 
almost total absence of the blind sac, the fundus ventriculi, on ac- 
count of which the contents of the stomach are not, as in the adult, 
driven toward the fundus during its peristaltic action, but forced 
directly into the cardiac orifice, and, when that opening is incom- 
pletely closed, a regxirgitation of the food will immediately take 
place. When the physician has an opportimity to see undressed 
infants vomit, he will readily convince himself that no abdominal pres- 
sure whatever takes place, but that at once, while the children are 
respiring normally, and displaying all the signs of perfect health, the 
mUk flows quietly out at the mouth. They do not, on the whole, throw 
up very large quantities of milk, and thrive excellently in this condi- 



DISEASES OF THE DIGESTIVE APPARATUS. 125 

tion, so that the old proverb of the nurses, " spitting children, thriving 
children," must be accepted as true. 

This vomiting occurs only in infants at the breast ; those brought 
up by the hand, it is true, also vomit very often, but here nausea, 
sleeplessness, and hot state of the body, precede the vomiting ; the act 
itself is combined with retching and contractions of the abdominal 
muscles, and its effects are digestive disturbances of all kinds and 
emaciation. The matter vomited does not consist purely of the undi- 
gested nutriments, of the cow's milk, of the broth, or the soups, but a 
large quantity of mucus is already mixed with it, and the cow's milk 
is curdled into large lumps. Those who see a child of about five years 
old affected with nausea, consider it dangerously ill, near its death ; 
the face turns deathly pale, the forehead becomes covered vrith a cold 
perspiration, the eye is heavy, the respiration profound, labored, and 
irregular ; the pulse is so small that it is barely perceptible. It lays 
down and moans lowly ; occasionally it puts its hands in the mouth, 
and bears an expression of the utmost anxiety upon its countenance. 
This condition may last several hours. Suddenly violent vomiting 
comes on, a large quantity of liquid food flows out of the mouth with 
a gush, a few retchings follow, accompanied by a loud outcry of the 
frightened child, and the whole morbid picture is instantly gone. 
Then, as a rule, a deep, long sleep succeeds, after which, if only an 
overloading of the stomach with coarse, undigested food was the cause, 
the child will wake up perfectly well, or at the most will suffer for a 
short time from a diminished appetite, and have a furred tongue. 

When children are attacked by an acute exanthema, typhus fever, 
or pneumonia, vomiting of the last-enjoyed meal, as a rule, takes 
place in the first day of the disease ; if that does not occur spon- 
taneously, I limit myself to mechanical means to induce it ; ipecacu- 
anha and tartar emetic should never be used, because they invariably 
act upon the bowels at the same time, and diarrhoea only aggravates 
the diseases. 

If a round worm has found its way into the stomach — an accident 
which happens but very rarely in children under one year of age, but 
in larger ones, on the contrary, tolerably often — then the acid contents 
of that viscus seem to disagree with it ; it moves rapidly about and 
excites antiperistaltic actions and vomiting, by which, to the great 
horror of the inexperienced parents, it is expelled. No bad effects 
are usually olaserved from this ; in general, however, such children are 
always afflicted with a great number of ascaris lumbricoides, and it is 
well to give them some vennifuge a few days after the vomiting. 

The vomiting in acute cerebral affections, in commotio cerebri, and 
particularly in hydrocephalus acutus, is of a very peculiar character. 



12Q DISEASES OF CHILDREN. 

When children affected with these diseases are turned over upon the 
other side or set upright, then suddenly, without their becoming 
thereby unpleasantly affected, if they are otherwise in possession of 
their faculties, a gush of muculent, white, or yellowish-green water 
will come out of the mouth, after which, without suffering any retch- 
ings or nausea, they will take to drink again or continue to sleep. All 
cases should therefore be carefully examined and closely observed, 
whether nausea and retching precede the vomiting or not. When 
these symptoms do not precede, then we have to deal with very serious 
cerebral vomiting, from which the vomiting of healthy nurslings first 
spoken of, and which also occurs without retching, makes the only 
exception. 

Treatment. — The vomiting of nurslings should not be interfered 
with so long as the nutrition of the child does not suffer therefrom, 
and no large quantities of milk are thrown up. But, when this is the 
case, the nursing of the child must be conducted in a different man- 
ner ; it should not be allowed to drink until it forsakes the breast of 
its own accord, but should be taken from it after half that time, and 
laid down as quietly as possible. Tlie crying that results therefrom 
soon ceases. By this procedure alone it is usually possible to prevent 
the too frequent and copious vomiting. If, however, this does not 
answer, a few teaspoonfuls of sweetened strong chamomile-tea should 
be given before the child is put to the breast. 

The vomiting of artificiallj^-nourished children is always a sign of 
enfeebled digestion, and is, tinder all circumstances, to be corrected. 
Here the treatment with carbonate of lime or carbonate of magnesia is 
excellently adapted, and leads, if in addition the diet is properly regu- 
lated, to the most satisfactory results. If the intestines are at the 
same time affected, if diarrhoea is present, these must be cured before 
a cessation of the vomiting can be expected. Here also, calomel, given 
in gr. one-sixth two or three times daily, stands at the head of the hst 
of all known remedies. 

AMien it is supposed that the child is nauseated, and only in con- 
sequence thereof is affected with restlessness and anxiety, then, for 
the mere purpose of inducing the act of vomiting, mechanical means 
alone usually suffice. The surest one is the direct compression of 
the stomach, which I accomplish by exercising a gradually-increas- 
ing pressure with the ends of the fingers from above the navel tow- 
ard the praecordia, accompanied at the same time by a rotary 
motion of the hand, whereby usually violent, sometimes perceptible 
contractions of the stomach ensue. If this procedure does not cause 
vomiting, I introduce the right index-finger into the mouth, depress 
the tongue and tickle the soft palate. If no vomiting follows upon 



DISEASES OF THE DIGESTIVE APPARATUS. 127 

this manipulation, then it may safely and surely be concluded that 
the child has no nausea, and that an emetic will hardly produce any 
favorable change in the condition. If the physician believes he has 
seen very positive signs of nausea in a child, which could not be 
made to vomit by these means, four to eight grains of powdered 
ipecacuanha should be strewed upon the root of the tongue, the jaws 
being kept apart with the fingers of the left hand, after which a few 
teaspoonfuls of water are administered. If this quantity is insuffi- 
cient, he may rest assured that the stomach has no contents that 
oppress it, and that by stronger emetics a vast amount of harm will 
be done. 

The vomiting of cerebral affections is only symptomatic, and to 
my knowledge cannot be arrested nor even mitigated ; when, in very 
rare instances, the acute hydrocephalus improves, the vomiting wiU 
cease spontaneously. 

Vomiting that occurs in commotio cerebri, produced by a blow or 
fall, if no injury to the cranial bones nor cerebral haemorrhage has 
resulted, lasts only one or a few days, and then gives place to a com- 
plete recovery. 

(d.) Flatulence and Colic. — If the gas, that is always physiologi- 
cally present in the stomach and bowels, increases in quantity, and 
the peristaltic movements of the intestines do not become accelerated 
to such a degree as to expel it by the anus, a distention of the stomach 
and bowels is produced, and, as a result thereof, an augmented ten- 
sion of the abdominal walls, which, if acute, has been called mete- 
orismus; when it has become chronic, flatulence, or tympanites. 
For this augmentation of gases the intestines are in greater part 
indebted to their own secretions ; for at no time is it more constant 
than immediately before and during diarrhoea. Constipation, it is 
true, also tends to flatulence ; it is, however, never so frequent nor 
so decided as that which accompanies diarrhoea. A diminution of 
the tone of the gastric and intestinal muscular coats is also always 
necessary, to produce a more intense degree of meteorism, without 
which the gases that originate would be quickly propelled toward 
the anus and be expelled ; this happens principally in typhus fever, 
sometimes also in the acute exanthema. The nutriments with which 
children under one year of age are supplied — bread, milk, broths, and 
amylacea — never cause any flatulence so long as they are tolerated; 
but when diarrhoea comes on, then it cannot be decided whether the 
intestinal distention is a result of the nutriments or of the intestinal 
secretion. 

Mechanical obstructions, carcinoma of the stomach or alimentary 
tube, strangulated herniae, peritoneal adhesions, constricting cicatrices 



128 DISEASES OF CHILDREN. » 

of ulcers, whicli in the adult cause such dangerous, almost fatal tym- 
panites, occur but very rarely in children, in nurslings never. 

Symptoms. — By flatulence we understand an enlargement of the 
abdomen, which may affect either the whole of the abdominal cavity 
or only some parts of it, according as the stomach and the whole 
of the alimentary canal, or only certain sections of the latter, become 
distended. 

It is usually assumed that, when the abdomen has a conical shape, 
the small intestines are dilated, when it is barrel-like distended, the 
large intestines are expanded, in which case, however, a complete 
cut-off would certainly have to exist between the large and small 
intestines, since air in spaces that communicate with each other must 
effect equal tension, and uniformly expand their boundaries. That 
such a complete cut-off ever takes place at the ileo-caecal valve is not 
probable, but an inequality in the tone of the muscular coat of the 
large and small intestines is very likely to happen. 

In acute diseases, particularly in abdominal tj^phus, the condition 
becomes materially aggravated by the tympanitis, for the lungs and 
heart thereby become compressed, and thus dyspnoea and disturbance 
of the circulation are liable to ensue. 

Colic is a pain that originates in the walls of the intestines ; it is 
mostly paroxysmal and exacerbating. It is, of course, only a symp- 
tom, in fact, of the most varying diseases of the abdomen, but flatu- 
lence is its most frequent causation, of which colic is the most 
constant symptom. In addition, colic pains occur in children, with 
every diarrhoea that has originated in consequence of anomalous 
irritations of nutriments, and are never absent when material alter- 
ations of the intestinal mucous membrane, when enteritis folliculosa 
or dysentery, even in their mildest forms, have once developed them- 
selves. 

Large quantities of round worms may produce violent colic pains ; 
single round worms frequently pass off from the children, having pro- 
duced no colic pains whatever, nor displayed any symptoms in par- 
ticular, as will be shown more fully further on, in the study of 
entozoa. There are also some children, who, every time they have 
caught a cold, especially if their feet have become wet, are suddenly 
attacked by colic, without the digestion before or during it being 
materially interfered with. Such children usually do not tolerate 
baths, nor even ablutions with cold water, but often for years have to 
be washed with warm water, and then only with the utmost pre- 
caution. 

The symptoms are usually as follows : Sudden painful contractions 
of the angles of the mouth and of the countenance in general, sudden 



DISEASES OF THE DIGESTIVE APPARATUS. 129 

ioud continuous crying, restless movements of the arms, stamping 
with the feet, contractions of the lower extremities upon the body, 
painfulness of the abdomen, increased on touching, and tympanitis ; 
in boys the scrotum is in a state of extreme contraction. Generally 
a discharge of gases or of fluid fasces soon takes place ; vomiting-, 
also, frequently follows. In very nervous children, and when the 
colic is of an extreme degree, convulsions may ensue. The principal 
cardinal points in the diagnosis are the complete intermissions of the 
pain, and the preceding digestive troubles. 

After all, the physician should never depend upon the statements 
of the parents, who are very much given to exaggerate every restless- 
ness of the child into colic pains ; he should cause the child to be 
completely undressed, and uninterruptedly watch it for ten or twenty 
minutes, and carefully examine it. Many mothers look upon the 
colic-cry as a hunger-cry, and hasten to fill the mouth of the child 
with milk, or even broth, and, what is very remarkable, they often 
succeed in quieting the child with a few teaspoonfuls, but only for 
a few minutes, and then, in consequence of the irritation produced by 
the newly-introduced food, it sets up a still louder and longer cry. 

Therapeutics. — The treatment of flatulence has for its object the 
expulsion of the gas from the alimentary canal, and this is best achieved 
by clysters. In most cases an ordinary injection with warm water, to 
which a few teaspoonfuls of oil have been added, suffices ; should no 
copious evacuation of faeces and gas follow, a clyster of cold water, 
without oil, or of a strong warm infusion of chamomile, may be tried ; 
the former tends to produce a sudden acceleration of the peristaltic 
action of the whole intestinal canal, which is often accompanied by 
manifestations of pain, and is therefore not appropriate when the colic 
preponderates ; the latter, on the contrary, is principally directed 
against the colic pains, and acts more as an anti-spasmodic than as 
a gas evacuant. Bladders filled with ice or cold water, or compresses 
applied to the abdomen, so much advocated in adults, act very un- 
favorably in small children, and aggravate the pain, without being 
followed by any relief. Temporary benefit can only be derived from 
such a method of treatment; an impression upon the causes of the 
flatulence cannot be made until the entire nutrition of the child 
has been examined, and the action of the various articles of food accu- 
rately observed. Tlnrough this examination it becomes evident, as 
already stated, that the diarrhoeic intestinal secretion generates large 
quantities of gas before it is evacuated, and consequently all articles 
of food, which cause the children slight diarrhoeic stools, produce 
directly also flatulence ; the most common preparations that belong 
to this category are the gruels, and especially all those prepared 



130 DISEASES OF CHILDREN. 

with cow's milk, and am3"laceous broths ; children at the breast rarely 
suffer from flatulence. It follows, that children about to be brought 
up by hand, who are predisposed to colic, must soon be habituated to 
meat-soups, which at first should be given slightly sweetened, and but 
once a day, later, twice daily, and without any sugar. I do not con- 
sider it necessary to restrict children to any particular kind of meat — 
veal and chickens are unnecessary luxuries — the main thing is that 
the soups are not too concentrated nor salty, and should be freed 
from oil-globules as much as possible. The best material to give the 
soup suitable consistence is pulverized wheat bread ; rice, groats, and 
mucilaginous soups are not tolerated long. 

During the attack, colic requires a symptomatic, and, subsequently, 
a causative treatment. The symptomatic treatment consists either 
in a cautious employment of narcotics, particularly the preparations of 
opium, of hydrocyanic acid and nux vomica, or in ethereal, aromatic 
remedies, chamomile, peppermint, or melisa teas, applied per os et 
anum. Above all, it is necessary to keep the patients warm ; this is 
readily accomplished by wrapping them up in warm clothes, by ap- 
plying to the abdomen bottles filled with warm water, or bags filled 
with warm chamomile-flowers ; warm drinks are also very beneficial. 

Tlie causative treatment has for its object the removal of the differ- 
ent causes : 

(1.) Colic produced by anomalous contents of the stomach and 
alimentary canal. Here, if possible, the stomach should be evacuated 
by mechanical means, or, if not, by four to eight grains of ipecac. 
"WHieu coarse, indigestible nutriments have once passed beyond the 
pylorus, they will produce diarrhoea by their OAvn irritation, and there 
will hardly ever be any occasion to induce it by remedies ; on the 
contrary, it often happens that the diarrhoea has to be arrested by con- 
stijiating remedies, because it has become too profuse. Worm-colic 
must be treated first by opium, to palliate the colic ; then, however, by 
proper doses of anthelmintics to expel the worms, a more detailed 
description of which will follow further on. Vermifuge remedies 
should never be given to a child suffering from diarrhoea and colic. 

(2.) Colic caused by impaction of stagnant alvine masses, owing 
to their generally rapid digestion and absorption, rarely occurs in cliil- 
dren. But fruit-seeds, especially of grapes and cherries, accumulate 
into large lumps, and the stools, notwithstanding the fruits partaken 
of, remain hard, and, if a large quantity has been swallowed, intense 
colic pains, and even sjnnptoms of intestinal stenosis, will follow. As 
these lumps of fruit-seeds almost always remain in the small intes- 
tines, clysters therefore do not suffice to remove them ; an augmenta- 
tion of the intestinal secretion must be obtained, to soften and make 



DISEASES OF THE DIGESTIVE APPARATUS. 131 

them liquid, for which purpose a few large doses of calomel, of four 
to five grains, will be found to answer. 

(3.) Colics depending upon textural alterations of the alimentary 
canal only require a symptomatic treatment, as has already been stated 
above ; the treatment of the textural diseases will be given more in 
detail in connection with their descriptions. 

Lead colic, arsenial colic, and all other toxical colics in general, must 
be treated as in the adult, by the respective antidotes which toxi- 
cology prescribes. 

(e.) Diarrhoea {diappoca, from dia, and pl«, I flow). — By diarrhoea 
we understand a qualitative and quantitative derangement of the ex- 
crements. The quality of the excrement evacuated is, aside from the 
chemical and microscopical properties, subsequently to be elucidated, 
in so far changed that it no longer possesses the semi-solid, pap-like 
consistence, but is now a watery liquid alone, or watery liquid in which 
fecal matter or remnants of food are suspended. The quantity is always 
increased in diarrhoea, but no very precise amounts can be given, be- 
cause, in the infantile age the stools cannot be properly collected, and 
the measurements give therefore only an approximative result ; the eye- 
measurement, however, suffices completely to confirm the statement 
that a larger quantity of alvine matter is evacuated in diarrhoea than 
in the normal state. That the anus has to open itself oftener than 
usual, in order to expel a larger quantity of excrement, requires no 
further comment. Owing to the irritation which the liquid alkaline 
intestinal contents exercise upon the sphincters, the defecation takes 
place oftener even than would be absolutely necessary in conformity 
with the total quantity of the feeces evacuated. 

Various kinds of stools may be distinguished, according to the 
form, color, and smell ; and furthermore, according to the chemical 
and microscopical properties. 

The normal form of the infantile feeces in the first year of life is 
the pappy ; the color is yellow, like that of the yolk of egg ; the smell 
is feebly acid, never putrid, and, only in children who are fed upon a 
meat-diet, as repulsively pungent as in the adult ; in later years they 
are no longer to be distinguished from those of the adult. 

Diarrhoea may consist simply of softer, more fluid, but yellow-dyed, 
and still feculent matters — diarrhoea simplex, stercoralis sive fusa — 
or undigested articles of food pass off with such constituted stools, 
a condition that has been called diarrhoea lienterica, lienteria (from 
leiov, smooth, and evrepov, intestines, laevitas intestinorum). These 
occur extremely frequently in artificially-brought-up children ; for 
the careless parents try from time to time whether they might not 
finally cease preparing extra dishes for the child, and allow it to 



132 DISEASES OF CHILDREN. 

eat from the general dish. They give the children meat, vegetables, 
and fruit. Occasionally, finely-cut pieces of meat are digested ; as a 
rule, however, the children, for want of teeth, swaUow larger pieces, 
which the gastric juice is incapable of dissolving, and these now pass 
through the whole of the intestinal canal as foreign bodies, and un- 
dergo decomposition. Vegetables and raw fruit are generally dis- 
charged in an undigested state, and often cause a very profuse, dan- 
gerous diarrhoea, sometimes none whatever. 

Again, there are diarrhoeie where the bright-yellow evacuations 
are so thin that they squirt out from the anus as from a syringe, and, 
like water, soak through the diapers and bedclothes. They occur 
principally in cholera nostras and asiatica, and in children who have 
only been just weaned, diarrhoea ablactatorum ; they are either totally 
odorless, or have a putrid but never the physiological acid smell, and 
never react acid, like the normal stools of children at the breast, but 
neutral, sometimes even alkaline, from the presence of large quanti- 
fies of the alkaline carbonates. If they have been collected in a clean 
vessel, and then pom-ed into a test-tube, they wiU separate into two 
strata, after the manner of tj'jDhus-fever stools; the upper one is 
bright, almost perfectly transparent, the lower flocculent, and mixed 
with small bro^vn feculent lumps; this lower layer is often very 
small, and forms but a tenth part of the upper. The microscopic ex- 
amination, besides the undigested remnants of food, such as vegetable 
cells, amyloid bodies, milk-globules, casein-coagula, etc., reveals noth- 
ing but intensely yeUow or light-brown-dyed scales, fragments of epi- 
thelium-cells, and a number of brown globules of various sizes, with- 
out enveloping membranes, as may be readily demonstrated by simply 
compressing them ; entire cylindrical epithelium-cells are rarely seen. 
In alkaline stools the triple phosphates are also found. Generally 
these stools do not contain albumen, but when they have a rose or 
reddish-bro\Am color, usually due to an admixture of small quantities 
of blood, then albumen may easily be detected by the aid of nitric 
acid. 

The green stools of children are commonly denominated " bilious," 
but without any correct foundation, for nobody has yet demonstrated 
that they contain more component parts of bile than yellow or brown 
stools. The coloring matter of the bile is originally brown, and the 
normal fseces on that account brown ; or, if the children are only 
fed upon milk, golden yellow. But the normal brown coloring mat- 
ter of the bile (the biliphsein) can very easily be converted by a num- 
ber of chemical agents, even by simple contact with air, into the 
green (biliverdin), and this, in the medication of children, very fre- 
quently happens through calomel. The supposition that the areen 



DISEASES OF THE DIGESTIVE APPARATUS. 133 

stools, after small doses of calomel, are due to a mecliamcal admix- 
ture of a substance covered with a black coating of sulphuret of 
mercury, is erroneous ; for (1.) These green-colored stools often last 
for several days, and are of large quantities, without it being possible 
to demonstrate the presence of mercury in them after the second 
day; and (2.) The stools may be diluted with water, and filtered, 
when the latter will be seen to run through the filter very green in 
color, proving conclusively that it is not a mechanical coloring. 

In young children green stools occur during dentition, and after 
almost every intestinal catarrh produced by undigested nutriments, 
and it seems that the augmented secretion of the intestines is sufficient 
to convert the biliphsein into biliverdin. It also very frequently hap- 
pens, that the fceces are evacuated perfectly yeUow, but turn to a 
green color when exposed to the air for a few hours. This change 
of color first begins at the periphery and on the thinner layer of the 
fecal masses ; and not till some time after do the denser, principal 
lumps become affected, until the whole is seen to be dyed uniformly 
green. Children with such evacuations usually suffer from slight 
dio'estive disturbances. 

In still another kind of diarrhoea, admixtures of large quantities 
of mucus occur, large and small lumps and shreds of Avhich being 
discharged with the almost liquid intestinal secretion, having the 
greatest resemblance to the glairy nasal mucus. They may be toler- 
ably well freed from coloring matter by agitating them with water ; 
they lose, however, thereby, in transparency, and under the micro- 
scope exhibit mucus-corpuscles, fragments of epithelium, and granu- 
lar masses. The evacuations of these are attended by pain. 

In artificially-reared, slowly-developing children, gray or bright- 
yellow colored, loamy stools are sometimes met with, which may be 
smeared like moist clay upon the diapers and with the greatest exer- 
tion only are expelled from the anus. This decoloration is due to a 
deficiency or absence of bile, or at least of the coloring matter of the 
bile, and, so far as I am aware, has no deleterious effect upon the di- 
gestion and development in particular. True, by the aid of the ex- 
tract, or a few grains of powdered rhubarb, an increased secretion of 
bile may readily be obtained ; the danger, however, is always thereb}^ 
incurred of inducing an intestinal catarrh, the end of which it is im- 
possible to foresee ; consequently more harm may be accomplished by 
it than good. 

The odor of the diarrhoeic faeces will always be of the greatest 
importance in judging the disease of the mucous membrane, and par- 
ticularly for the prognosis. Of a number of stools, having the same 

appearance and the same degree of fluidity, some will have scarcely 
10 



134 DISEASES OF CHILDREN. 

any odor, others will smell simply fecal, and still others fetid and 
'putrid. These last are always sj-mptomatic of a grave disease, of 
enteritis folliculosa, which in most instances terminates in death. The 
odor is difficult to be described, but may be best compared to sul- 
phuretted hydrogen ; it is often so offensively pungent, that the care of 
such children can only be properly carried out by great sacrifices on 
the part of the attendant, the rest of the occupants of the room in 
which the cliild is confined beino; oblio^ed to vacate it. These stools 
are also evacuated with pain, and redden the anus and its adjacent 
parts. Most frequently they are met with as accompaniments of 
thrush, in which the anus, genitals, inner part of the thighs, and heels, 
appear intensely reddened, and, in parts, also eroded. Microscopically 
and chemically, I could detect no special distinguishing characteristics 
in these stools, and, with the exception of the odor, know no pathogno- 
monic peculiarity to mention. 

Pus probably never occurs in the stools of small childi-en ; in those 
of larger ones it may sometimes be seen after dysentery has been 
arrested. Most tubercular idcers of the bowels are situated in the 
small intestines, and their discharges are not so copious that whole 
streaks of pus, for these only are meant, can be found in the stools. 

(f.) Obstijyation [Ohstructio Alvi), Constipation. — When other- 
wise health}^ children, under one year of age, have not two evacua- 
tions, and those from one to three years at least one stool a day, the 
consistence of the fasces becomes hard, and a condition results that 
has been called obstructio alvi. Artificially-reared infants are mainly 
subject to it ; still it is also sometimes seen in children at the breast, 
especially in those whose wet-nurses suffer from this evil. The chemi- 
cal investigation of the milk of such wet-nurses leads to negative re- 
sults. 

The causes of constipation are found in the following conditions : 

(1.) Deficient or too tenacious intestinal mucus. The constipation 
of most febrile affections is mainly due to this condition, or to aug- 
mented perspiratory and m-inary secretions. 

(2.) The nutriments, especially the amylaceous class, soups con- 
taining meal, rice, sago, etc. In older children the various dishes con- 
sisting of beans, peas, and the like. Again, all nutriments and medi- 
cines containing astringents, red-\vine, the preparations of lead, alum, 
iron, bismuth, chalk, nitrate of silver, and vegetable remedies con- 
taining tannin ; all these may produce constipation, which will last for 
some time. 

(3.) Too slight peristaltic movement of the alimentary tube, which 
is scarcely ever observed as a primary but mostly as a secondary con- 
dition, the effect of disease in other organs. Here belongs the obsti- 



DISEASES OF THE DIGESTIVE APPARATUS. I35 

nate constipation of acute hydrocephalus, in which, notwithstanding 
its long duration, the abdomen always remains depressed. In atro- 
phied children, in ultimo stadio, besides the diminution of the intestinal 
secretions, atrophy of the muscular coat of the bowels becomes super- 
added, and then constipation ensues through a double cause, and 
finally a peripheral paralytic state of the bowels also occurs, especially 
in mechanical or perforative peritonitis. 

(4.) Mechanical obstructions, incarcerated herniiB, intussuscep- 
tions, tortious, complete occlusion of the calibre of the gut by firm, 
dry stercoraceous masses, etc., occur extremely rarely in children. In 
uew-bom children, imperforatio ani, a description of which will follow 
further on, must be taken into consideration. 

The description of the symptoms is almost exhausted by the defi- 
nition of the malady. The abdomeii is distended, but, in simple con- 
stipation, not painful to the touch. The sparsely-evacuated fseces 
lay dry in the diapers, like those of the goat or sheep. When the 
evil is of long standing and intense degree, the tympanitis increases 
so much as to push the liver upward ; the spleen cannot be detected 
by percussion, and the whole abdomen feels as tense as the head of a 
drum, on account of which, it will naturally be painful to the touch. 
Then the children leave off eating, are very restless, attacked by 
eructations, and finally by vomiting, some fetid intestinal gas passes 
ofi", with slight temporary relief, but all the symptoms disappear at 
once, if one or more copious evacuations have been produced. 

Wlien the disease is of long duration, the tympanitis becomes 
chronic. Owing to the protracted anorexia the patients become very 
much reduced, and, as a result of the continuous compression of the 
abdominal veins, a marked collateral venous circulation forms beneath 
the abdominal integument. 

In every serious constipation it is advisable to examine the anus 
and rectum with the fmger, because we may thereby often dispense 
with the internal treatment. Hernia is frequently the effect of this 
evil ; and convulsions in small childi-en. If no mechanical insurmount- 
able hinderances, as those enumerated in sec. 4, are present, the prog- 
nosis may be regarded as favorable. 

Therapeutics. — The treatment must fathom the cause ; therefore, 
the diet is, first of all, to be tested and regulated. A slight modifica- 
tion of the nutrition often suffices to relieve the evil, as, for instance, 
meal food is to be allowed only once instead of three times a day 
to the child, and more milk given than heretofore, or the very con- 
stipating mucilaginous soups are substituted by thin beef broths 
with some wheat bread, which is made to form the staple of the 
daily nutriment. In somewhat older children the stools may be readily 



136 DISEASES OF CHILDREN. 

aug^uented bj alloAving them boiled and also laAV fruits, grapes, ap- 
ples, pears, etc. ; next by a plentiful supply of cold Avater, and it is 
esjDecially adA^isable to try to remedy the constipation by a change of 
diet, before aperient remedies, of Avhatever kind they may be, are re- 
sorted to. If no success has attended this simple method of subjugat- 
ing the evil, one or two teaspoonfuls of I^. rhei aquosa should be 
given, as it is always the best and least injurious. Calomel should 
never be resorted to for the mere purpose of promoting the stools, 
when no other indication for it exists, for the very reason that 
mercury cannot be cleared of the suspicion that it tends, in many 
cases, to retard the development of the child, and promotes caries of 
the teeth. A small suppository of common soap introduced into the 
rectum will fi-equently relieve the constipation. Clysters of cold 
water or of soap-Avater have the double effect of softening the hard 
fecal contents of the rectum, and, hy consensual irritation, of stimulat- 
ing the whole intestines into increased peristaltic action, and of aug- 
menting the secretions thereof. But when the fecal masses are very 
compact, it will not be possible to employ clysters, for the Avater will 
flow out again even during the injection, and we have no other alterna- 
tive but to remove them by mechanical means, by the aid of a hair-pin, 
scoop, or the like. Constipation accompanpng febrile diseases, and 
that originating as an effect of acute hydrocephalus and of peritonitis, 
very seldom become objects of special treatment, and will he spoken 
of in the relative sections. 

(2.) Catarrh of the Gastric Mucous Membrane [Catarrhus 
Ventriculi). — CataiTh of the mucous membrane of the stomach, or 
gastritis catarrhalis, is met with in the autopsies of many children, who, 
during life, exhibited no signs whatever of disturbed digestion. When 
we bear in mind that a bright-red color of the gastric mucous mem- 
brane is a physiological condition in the new-born, it VAdll not be pos- 
sible to lay very great stress upon the frequently-described injections, 
and still more of the ecchymosis of that mucous membrane, especially 
as we have no guide whether any, and, if any, Avhat symptoms are pro- 
duced thereby. Only when a blennorrhcea of the gastric mucous 
membrane has developed itself, and the profusely-secreted mucus is 
vomited several times a day, are we justified, from a clinical point of 
view, to diagnose a gastric catarrh. The causes of this affection are 
as numerous as those which have been enumerated in the previous 
sections for dj'spepsia, vomiting, flatulence, etc. 

Symptoms. — The symptoms of such a gastric blennorrhcea are fixed, 
continuous stomach-ache, increased on pressure, permanent distention 
of the epigastric region, perceptibly increased temperature of the 
same, and an accumulation of gas within the stomach. Warm or 



DISEASES or THE DIGESTIVE APPARATUS. 137 

solid nutriments and warm drinks, introduced into the stomach, aggra- 
vate the pains ; cold drinks, particularly cold milk, relieve them. 
True, the food is frequently thrown up, but upon that alone the 
diagnosis of gastric catarrh cannot be based; an emesis of pure, 
opaque, glairy, or greenish mucus, without much retching, must 
take place before or some hours after the meal. The nutrition 
of the child is not much interfered with at first, because, as has been 
already observed, the food is not regularly thrown up, and the intestinal 
mucous membrane is still capable of absorption. But in the course of 
time emaciation comes on. In the cadaver the gastric mucous mem- 
brane is found hyjoertrophied, covered with a thick layer of mucus, its 
upper surface imeven and warty, a condition that has been called 
etat mamelonne by the French ; but it is only necessary to observe here, 
that, before a mucous membrane can be called mammellonated, the 
contracted stomach should have been stretched out to its fullest capa- 
city, for, in the strongly-contracted stomach, every mucous membrane, 
even the healthiest, will assume a warty appearance. The rest of the 
symptoms enumerated in text-books, those regarding the pulse, the 
general condition, the stools, the urine, etc., are not sufficiently char- 
acteristic to deserve a place here. 

Therapeutics. — The chief object of the treatment is to regulate the 
diet, and nothing but cold milk should be allowed for several days. 
Against the profuse secretion of the mucus, nitrate of silver has proved 
to be a sovereign remedy. To small children under one year and 
up to two years of age, I give a solution containing nitrate of silver, 
gr. ss. to water 5 iij, without syrup, or any mucilaginous addition. 
To children several years old who are adepts at swallowing pills, \ 
gr. nitrate of silver each will be found to act better than the solution. 
I recollect but a single instance, that of a boy eight years old, in 
whom I was unable to accomplish any satisfactory results with this 
method of treatment. For ten days he took four to six nitrate-of-silver 
pills without any effect, whereujDon I ordered him five drojos of creosote 
in five ounces of mucilaginous vehicle, and, to my great surprise, the 
vomiting of mucus was suddenly arrested by it. Nitrate of silver, 
cjeteris paribus, will always be preferable to the creosote, owing to 
the unpleasant odor and disagreeable taste of the latter. Compare the 
treatment of vomiting, page 126. 

(3.) Toxic iKPLAiniATioK of the Stomach. — All children are 
lickerish, and junket whenever they get a chance, and thus it not un- 
frequently happens that children from one to five years of age, espe- 
cially in manufacturing cities, where a great deal of strong acids and 
caustic alkalies are used, hurriedly swallow large quantities of sul- 
phuric or nitric acid, caustic alkali, caustic lime, common lye or car- 



138 DISEASES OF CHILDREN. 

bonate of soda, and a considerable quantity may have already found 
its way into the stomach, before they become aware of their dis- 
astrous error. The discussion of the general effects of caustic poisons 
belongs to the forum of Toxicology ; we will therefore limit ourselves 
to a descriiotion of the morbid changes of the stomach and intestines. 

Symptoms and Anato mo-pathological Characters. — The state of 
the mouth is the surest index by which to judge of the lesions within 
the stomach. Its mucous membrane, from any concentrated caustic, is 
found converted into a whitish-gray mass, on the removal of which 
the submucous tissue is seen to be dark-red, and sometimes bleeds 
considerably. Only in case nitric acid has been swallowed will the 
mucous membrane be dj-ed yellow, and less softened than shrunken. 
If a large quantity and very concentrated caustic has been introduced 
into the mouth, the submucous tissue will also be implicated in the 
destruction, and, at the first sight, one may be led to believe that 
he has a diffused gangrene of the mouth before him, as in noma, for 
instance. A similar condition is found in the stomach. The milder 
degrees of cauterizations with weaker escharotics, or when such small 
quantities have been swallowed that, by becoming diluted with, the 
gastric contents, they are barely Ciipal^le of acting as escharotics, wall 
hardly ever offer an opportunity for an anatomo-pathological examina- 
tion, for the lethal termination takes place, if at all, at a much later 
period, but in most instances does not follow at all ; in those cases 
that prove rapidly fatal the mucous membrance is found destroyed, 
in black shreds, the muscular and serous coats lax and usually per- 
forated, and the contents of the stomach already escaped into the 
peritoneal cavity. Even the duodenum may be encroached upon by 
the cav;stic, but the morbid appearances of the bowels, in comparison 
with those of the stomach, are very slight. Death, b}' perforation of 
the stomach, happens less frequently in lickerish cliildren than in sui- 
cides, who with premeditation swallow a large quantity of corrosive 
liquid, but gastric and oesophageal ulcers will frequently ensue (vide 
Qllsophagitis, page 118), which heal but very slowly and with hard 
cicatrices. 

The symptoms accompanying these accidents vary according to 
the quantity and strength of the escharotic, according to the depth 
it has penetrated into the stomach, and according to the quantity of 
liquid food or fluids present in the stomach at the time. Usually, im- 
mediately upon the introduction of the caustic into the mouth, retch- 
ing and a spasmodic closure of the oesophagus take place, as a result 
of which it does not enter the stomach at all, but is expelled again 
by the mouth. The case is far worse when the stomach has also be- 
come corroded. The patients then lie in the greatest suffering, and 



DISEASES OF THE DIGESTIVE APPARATUS. 139 

Btir very little, because the intense gastric pains become still more 
aggravated thereby, and a bloody saliva, sometimes mixed with black 
vomited lumps, flows constantly from the mouth. The patients are 
completely aphonic ; every act of deglutition induces the renewal of 
violent pains, or even syncope and convulsions ; a cold perspiration 
covers the face, the eyes roll anxiously about, sink deep in the orbits, 
and are surrounded by a wide dark circle. The pulse is small, scarcely 
perceptible, and the surface of the body cyanotic. If the escharotic 
has come in contact with the alimentary canal, bloody diarrhoea will 
also supervene. If the phenomena have attained the above high de- 
gree of severity, death soon takes place, generally from perforation 
of the stomach ; and, even if the latter does not happen, it apparently 
occurs in consequence of paralysis of the pneumogastric nerve. When 
death does not ensue in the first few days, recovery usually takes 
place after months of suifering, attended by alarming emaciation. 
Abnormal agglutinations, changes in form, and formations of diver- 
ticulee or strictures, may nevertheless be left behind for life. 

Therapeutics. — The treatment in poisoning with caustic or alka- 
line carbonates is to neutralize them as quickly as possible by the aid 
of diluted vegetable acids, i. e., vinegar, lemon-juice, or the like, or 
to saponify them by administering some fatty substance, such as 
almond or olive oil, which should be administered in cupfuls. Either 
of these agents may be found in every house, and therefore there is 
no necessity whatever to previously administer mucilaginous sub- 
stances, the effects of which are by no means certain ; still less are 
emetics indicated, since spontaneous vomiting always occurs without 
them, besides which the violent contractions of the stomach, induced 
by emetics, enhance the ultimate occurrence of perforation. 

Corrosive acids likewise require to be neutralized as rapidly as 
possible, and for this purpose magnesia usta is best adapted ; but, as 
this article is not often found in dwellings, it has to be sent for ; con- 
sequently, a certain amount of time is lost, which may cost the child 
its life ; it is best, therefore, to administer soap-water or scraped 
chalk : in the use of these, however, a large amount of carbonic acid 
is generated, which, before being expelled by eructations, may in- 
duce a dangerous distention of the stomach. Ashes and common lye 
should only be used with the greatest precautions, and greatly di- 
luted, otherwise they may themselves produce further erosion. If the 
threatening symptoms have been palliated by the means here pre- 
scribed, opium will then be the best and most rational remedy to 
assuage the pain and arrest the peristaltic action of the stomach. As 
many drops, less one, of laudanum are to be given as there are years in 
the age of the child, and this dose should be repeated every two hours 



140 DISEASES OF CHILDREN 

till rest and slight narcotism ensue. In these accidents cow's milk 
has proved to be the best nutriment, upon which even older children 
may subsist for many weeks ; at first it may be given cold, and after- 
ward to suit the taste. 

(4.) The Perforating Ulcer of the Sto^iach ( Ulcus ven- 
tricull rotundum sive ^^e^lforans). — The perforating ulcer of the 
stomach is of extremely rare occurrence in children under ten years of 
age ; on the other hand, it frequently becomes developed in chlorotic 
girls before the commencement of pubert}^ Consequently, we have 
not strictly to treat of a disease of childhood ; we therefore only men- 
tion it for the purpose of enabling one to exclude it in a doubtful 
diagnosis of a gastric affection in a child under ten years of age. 
But when older children, especially girls, suffer from it, then its 
symptoms, jjathological anatomy, termination, and treatment, differ in 
no respect from what is observed in the adult. We therefore refer 
the reader to the classical works of RokltansJcy, Cruveilhier, and 
Bamberger^ in whose work on " Diseases of the Chylopoetic System " 
an exhaustive description of this condition may be found. 

(5.) HEMORRHAGIC ErOSIONS OF THE GaSTRIC MuCOUS MeM- 

BRANE. — In many autopsies of children, who have died from the most 
dissimilar diseases, a varying number of minute extravasations of 
blood are seen upon the gastric mucous membrane. They appear 
either as round spots, from the size of a millet-seed to that of a pea, 
or as long, narrow streaks, and are situated upon the most elevated 
portions of the congested mucous membrane. At these points the 
mucous membrane is either of a livid color and bloody in appearance, 
or, if the disease has been of some duration, it will present the shal- 
low depressions resulting from loss of substance. Brownish-red 
fibrinous flakes generally cover such spots, and the lesions described 
are only brought into view after they have been removed. I have 
never met with an instance where the submucous and muscular coats 
were involved in the erosion. 

These erosions are most frequent and numerous in the pyloric 
region. Whether they originated in the glands of the gastric mucous 
membrane, on account of which Ci'uveilhier would have this affection 
denominated gastritis folUculosa, it is impossible to decide, in the 
cadaver, as the ecchymosis does not limit itself to single mucous folli- 
cles, but is diffused over large surfaces in round or oblong patches. 

The symptoms conformable wnth the fact previously stated, that 
the erosions may be found in the stomachs of children who have 
died from the most dissimilar diseases, are very unreliable and insuffi- 
cient. They are frequently met with in tuberculous and atrophic 
children. They also often occur in children who have been treated 



DISEASES OF THE DIGESTIVE APPARATUS. 14^ 

with antim. et potass, tart, and other emetics, as "v^ ell as drastic purga- 
tives, or who, toward the termination of their last sickness, suffered 
from spontaneous vomiting. On the whole, however, it would be too 
presumptuous to say that they might not be found in children in 
whom none of these conditions had existed, and who die from such 
different diseases as lobular or lobar pneumonia, pyaemia, etc., so that 
it is difficult to mention any symptoms of this ^^ost-inortem condition 
which would indicate its existence during life ; consequently this 
affection has only an anatomo-pathological interest. 

APPENDIX. 

SoFTEiq-iNG OP THE Stomach [Gastromalacio). — Softening of 
the stomach is not a disease, but only a post-mortem condition ; but, 
since many authors and experienced physicians still doubt its post- 
mortem origin, the explanation of the condition will be given, further 
on, more minutely than its simplicity in reality seems to require. 

Before the appearance of Jdger''s article, softening of the stomach 
was regarded by all as a post-mortem condition, a self -digestion of 
the stomach occm-ring after death ; in this sense it was that 3Ior- 
gagni and Hunter, later Armstrong^ Treviranus, and Carswell, wrote 
on it. Then Jager came forward, in 1811, with his discovery of a 
neio disease^ softening of the stomach, which he described in several 
articles published in IIufela7id^s Journal of Practical Medicine. The 
symptoms of the new disease, as Krexiser afterward very correctly 
jDointed out, were identical with those of common cholera infantum. 
It first manifested itself by fever, irregular breathing, pain in the 
abdomen, intense thirst, anorexia, vomiting, and diarrhoea, to which, 
in a very short time, extreme emaciation, constant restlessness and 
sleeplessness, coldness of the face and extremities, and death, almost 
invariably succeed. 

It was not long, however, before it was found that this group of 
symptoms was not adapted to all gastromalacise discovered at post- 
mortem examinations, and the affection was therefore divided into 
two forms, an acute and chronic. For the acute the symptoms just 
described were retained as correct, death following on the seventh or 
eighth day ; the transition of the acute into the chronic form was said 
to take place as early as the fourth day. This latter form, however, 
it was claimed, in addition, might be developed by symptoms which 
at first were very slight, the subjects at last apparently perishing 
from atrophy. As almost every child in the course of its life has 
had one or more attacks of vomiting and diarrhoea, it was therefore 
very convenient, as often as this post-mortem softening of the stomach 



142 . DISEASES OF CHILDREX. 

was found, to constitute the chronic form. Tliat in a large numbei 
of children, who died from acute summer complaint, the so-called 
cholera nostras, no trace whatever of gastromalacia could be found, 
was ignored for a long time. Later on, however, doubts, as to 
whether there was any connection between the pathological condi- 
tion and the artificial complication of symptoms, increased to such a 
degree that they finally received due attention. Among these, first 
of all, was Virchoio and his pupils ; next Eiigel, Sednar, Oppolzer^ 
]B amber ger, TT. iLing, and Trousseau. These were, and in part 
are still, opposed by a ntunber of German and French physicians, 
who, according to JBamberger, may be classified in the following 
groups : Louis, JOallemand, JBillard, liicJiter^ and Nagel, regard the 
softening as a product of inflammation. A.ndral, Cruveilhier^ 
IBerndt, and TFeViter, believe it originates from an altered condition 
of the secretions, as well as from irritation and congestion. JCiger, 
Caraerer, Authenrleth, Schonlein, J^aumann, 3Iost, Teuffel, and 
others, attribute it to an altered state of the nervous system, a neu- 
rophlogosis, or neuroparalysis. Even MokitansJcy — at least in the 
older editions of his Pathological Anatomy — considered this as prob- 
able, and, in addition, assumed for another list of cases degeneration 
of a dyscrasic nature. Canstatt seeks for the cause in an altered 
state of the gastric secretion, and Eismann even attributes it to a 
peculiar miasma. 

Lastly, there are a large number of physicians who would side with 
both parties, for they grant that the softening of the stomach was 
commenced during life, but claim that it reaches the highest degree, 
and even perforation, only after death. To these Chaussier, Meckel, 
and, in part also, Andral, belong. 

JElsiisser, in a monograph published in 1846, threw the most 
light into this complicated disjjute. In it he demonstrated whj-, and 
under what conditions, the softening takes place in one cadaver and 
not in another. But before we enter more minutely upon the rea- 
sons for the cadaveric nature of the gastromalacia, it would be best 
to describe its anatomo-pathological condition. 

By gastromalacia we imderstand that morbid alteration of the 
stomach, in which its coats are softened or destroyed either by an 
ulcerative process or by the formation of pseudo-plasma, indepen- 
dently of any inflammatory action whatever. The seat of these alter- 
ations, in the great majority of cases, is the blind sac or fundus, and, 
by preference, its posterior wall. Why just these parts should be 
most frequently attacked is manifest from the dorsal decubitus in 
which the infantile cadavers are always placed. The mucous mem- 
brane is always the first of the tissues attacked ; not till this mem- 



DISEASES OF THE DIGESTIVE APPARATUS. 143 

brane is destroyed does the process invade the muscular and then the 
serous coat. These conditions may be readily and cleai-ly demon- 
strated at the points of transition, from the softened parts of the 
stomach to those which have remained uninjured. 

Two Idnds of softening have also been distinguished, a gelatini- 
form and a hlach. In the gelatinous form the affected places are 
changed to a yellowish-green, jelly-like tissue, and in the black into 
dark brown or blackish. The dark or bright color depends entirely 
upon the larger or smaller quantity of blood in the stomach at the 
time death took place. The more vascular the gastric coats are, the 
darker will the softened places appear. Sometimes the softening 
limits itself so precisely to the mucous membrane and submucous 
tissue, that the muscular coat appears as if exposed by the anatomist ; 
but when this coat also is destroyed, then the serous coat, the only 
one intact, assumes a gauze-like appearance, and readily tears in the 
attempt at removing the stomach from the abdomen. In other in- 
stances the stomach has ruptured before the abdomen is opened, 
and its contents escaped into the peritoneal cavity. But it should 
here be borne in mind that no reaction of the peritonseum, con- 
gestion, or purulent effusions, have ever been found in such perforated 
stomachs. 

No well-defined limits of the softened parts are ever noticed, as 
they gradually become superficial and lost in the normal mucous mem- 
brane without any inflammatory or even congestive demarcation. 
As regards the contents of the stomach, ElsiissQr was the first to call 
attention to the fact that a softened stomach is never found empty — 
that is, filled only with mucus, and that the liquid food always pres- 
ent has a strong acid reaction. In the majority of softened stomachs 
the contents consist of curdled milk. Often those organs adjacent to 
the stomach become implicated in the softening without perforation 
having taken place. The spleen, the left half of the liver, the dia- 
phragm and oesophagus, may be affected with the softening ; and thus 
if the latter, from rough handling of the corpse, has burst, Avhich 
often occurs, the liquid food will be found to have escaped into the 
left pleural cavity. Even softening of the pulmonary tissues and 
liquid food in the bronchi have been observed. This will have to be 
explained by the supposition that, while the infantile corpse was 
moved about or raised for the purpose of cleaning, some of the gas- 
tric contents flowed back into the pharynx, and then through the 
glottis down into the bronchi, Avhcre this material, causing softening, 
begins to act the same as in the stomach. Moreover, in most cases, 
morbid changes are found in the rest of the organs sufficient to ex- 
plain the cause of death. The following reasons may now be ad- 



144: DISEASES OF CHILDREN. 

vanced for the j^ost-mortem nature of the gastromalacia and for its 
aon-existence during life : 

(1.) Softening of the stomach always affects the most dependent 
part of that viscus, in which, according to the laws of gra\"ity, its 
contents accumulate ; therefore, under ordinary circumstances, in the 
dorsal decubitus of a corpse, the fimdus, and by preference its poste- 
rior parietes, are softened. That the softening of the mucous mem- 
brane always occurs only at those places where the liquid food has 
been in contact Avith them for some time, may be easily demonstrated 
in animals killed immediately after being fed with some fermenting 
substance, and the cadavers placed in different postures, upon the back, 
upon the belly, upon the right side, or hung up. Elsdsser has also 
applied this test to the infantile cadaver, having placed one, imme- 
diately after death, upon the right side for twenty-two hours, and he 
found the fundus intact, but the right side of the stomach, the half 
toward the pylorus, in a softened state. The mucous membrane at 
this portion of the stomach was wholly converted into a muco-gelatinous 
mass, the muscular coat partially so ; the contents of the stomach 
consisted of a liquid gray material, mixed with curdled milk, of the 
odor of whey, and having an acid reaction. These experiments 
show conclusively that gastromalacia does not exist at the moment 
of death, and is only developed when peculiar gastric contents in the 
cadaver come in contact with the walls of the stomach. They show 
further that the surfaces of the stomach, in contact with its contents, 
correspond to the dimensions of the softened portions. In a body, 
which, until the post-mortem examination, has laid undisturbed, the 
softening of the stomach will never be found to extend beyond the 
space embraced by the liquid food. 

(2.) Direct experiments, particularly those instituted by Elsdsser, 
and after him repeated and confirmed by many others, have sufficed 
to prove that the healthy stomach removed from a cadaver is not 
only capable of undergoing softening in any acids, but also in any 
fermentable substances, such as milk and sugar, so long as it main- 
tains the normal temperature of the body. 

(3.) Direct experiments on dogs and rabbits have proven that 
when perfectly-healthy animals, fed on milk or substances con- 
taining vegetable acids, are killed during the process of digestion, 
and allowed to remain for twenty-four hours in a proper temperature, 
softening in the highest degree and perforation of the stomach take 
place. In rabbits an almost total disappearance of the stomach is 
sometimes noticed under these circumstances, nothing remaining of 
the destroyed organ but loose mucus adherent to the still remaining 
portions of food. This condition is frequently met with in the ^^o^sf- 



DISEASES OF THE DIGESTIVE APPARATUS. I45 

mortem examination of suicides, of the executed, and, in many in- 
stances, of sudden death. 

Softening of the stomach, then, may be artificially induced outside 
of the body, in most animals, by a very simple procedure. 

(4.) Children attacked by cholera nostras, who, according to the 
alleged identity of the symptoms of cholera nostras with those 
of gastromalacia, suffer also from the latter, recover frequently, and 
immediately thereafter may die from another disease. No trace, 
however, of a cured gastromalacia has ever yet been found in the in- 
fantile cadaver ; and yet such a destruction as occurs even in the mild- 
est grade would probably give rise to marked cicatrices or contrac- 
tions of the affected parts. Nor, as has already been stated, have 
any traces of reaction or demarcation ever been found in a softened 
stomach, such as otherwise occur in all vital processes. 

(5.) The symptoms which should characterize softening of the 
stomach during life are variously given by authors. Most of them, 
in fact, describe the symptoms of cholera nostras, others observe 
cerebral compression or cerebral irritation, and still others only 
the usual atrophy, out of which the chronic softening of the stomach 
is then construed. Moreover, the symptoms of cholera nostras do not 
harmonize with the pathological changes of gastromalacia. It is very 
improbable that a stomach affected with softening would be constant- 
ly disposed to such active contractions as is jiecessary to produce the 
act of vomiting. And if the children were affected with softening of 
the stomach during life, and should vomit, then pure hlood ought cer- 
tainly to be thrown up, for the arteries of the softened parts are oiot 
obliterated, as is known to all anatomists acquainted with minute 
injections. 

(6.) The nervous system has been called upon for assistance in 
various ways by the vitalists, as those physicians are termed who re- 
gard the softening of the stomach as a process which occurred during 
life, to explain their theory. The doctrine of semi-paralysis of the 
vagus nerve seemed adapted to explain all the symptoms, particu- 
larly the absence of pain and reaction, sustained as it was by the 
frequent occurrence of softening of the stomach in cerebral and 
pulmonary affections. JElsiisser, on the contrary, very appropriately 
observes that pathological changes within the cranium, like soft- 
ening of the stomach, occur frequently in children, and their coin- 
cidence will continue to be suspected as accidental, until extensive 
statistical tables shall have shown how often cerebral affections 
occur in children independently of gastromalacia, how often gas- 
tromalacia has been found by itself, and how often both togethec 
According to the statistics hitherto collected, Elsiisser denies the 



146 DISEASES OF CHILDREN. 

existence of a relation between cerebral affections and softening 
of tlie stomach. The exjDeriments instituted by Camerer^ to prove 
the influence of vagus paralysis, have no merit whatever. For ex- 
amj^le, he found that the stomachs of healthy rabbits, in which 
the contents of the softened stomachs of infants were introduced, suf- 
fered no bad effects whatever therefrom ; but in rabbits, in which the 
pneumogastric and sympathetic nerves of both sides had been di\dded 
before the contents of such stomachs were introduced, death ensued 
in about sixteen hours, and that in one case, six and a half hours after 
death, all the coats of the stomach were found markedly softened ; in 
another, seventeen hours after death, the greater part of the fundus 
of the stomach was dissolved. Unfortunately, he neglected to per- 
form the counter-experiment with a healthy rabbit, viz., to divide the 
pneumogastric and sympathetic nerves without introducing the con- 
tents of softened stomachs, and then observe whether softening had 
taken place. Even perfectly-healthy rabbits exhibit softening of the 
stomach under this experiment, providing the animal be killed soon 
after the contents of a softened stomach of a child, or any other acid- 
ulous nutriment, has been administered to them, otherwise the in- 
jurious contents will be propelled onward into the alimentary canal 
by the action of the digesting stomach, and thus be divided too much 
to answer that purpose. That the stomachs of rabbits thus operated 
on underwent the process of softening, although they retained vitality 
for sixteen hours after the acidulous gastric contents had been intro- 
duced into them, is readily explained by the paralysis of the muscular 
coat of the stomach which it produces. As a result, the contents of 
the stomach remained unmoved till death ensued. But to assume at 
the same time a paralyzed state of the nerves of the stomach, and a 
" super-acid " gastric secretion, as is also maintained by some authors, 
is physiologically incorrect, because Tledonann, and many physiolo- 
gists after him, have demonstrated the fact that, after the division 
of the pneumogastric nerves, the gastric juice is found to be neutral, 
or, at least, less acid than in the normal condition. 

Thus, then, according to my judgment, sufficiently weighty rea- 
sons have been given — each one of which is enough — to piove 
softening of the stomach not a disease ; and it is only to be wished 
that many other time-honored and unquestioned pathological condi- 
tions could also be as accurately and positively proven to be what 
they really are. 

(6.) Catarrhal iNFLA^niATiox of the Ixtestixes {Catarrhus 
Intestinalls). — As the stools of intestinal catarrh have already been 
described in the section on " Diarrhoea," it remains only for us to speak 



DISEASES OF THE DIGESTIVE APPARATUS. 147 

of the pathological anatomy of the disease — etiology, symptoms, ter- 
mination, and treatment. 

If a child acquires an acute intestinal catarrh during the last few 
days of life, and succumbs to it, the mucous membrane of the small 
and large intestines will be found generally turgid, in some places 
either dentritically injected or traversed by a diffused, livid redness, 
the injected places generally corresponding to the angular curves of 
the gut. The solitary glands, especially in the large intestines, are 
seen to be distinctly swollen, and to project like small whitish promi- 
nences — of the size of pins' heads — above the reddened mucous mem- 
brane. They contain the same cells that are found in them in the 
normal state, but in much greater numbers. If the intestinal catarrh 
has existed but a short time, these lenticular follicles and Peyer's 
glands, which, in fact, are only to be regarded as lenticular follicles 
occm-ring in clusters, will never, or very rarely, be found ruptured ; 
whereas in chronic intestinal catarrh they are usually seen to be rup- 
tured, and here and there dyed with black pigmentary matter. Over 
large tracts of mucous membrane the newly-formed epithelial cells 
having been cast off prematurely and rapidly (the essential phenome- 
non of intestinal catarrh), do not again assume the character of jorimi- 
tive cylindrical epithehum, but retain the circular form of mucus 
corpuscles. The whole mucous membrane, as a result of the aug- 
mented afflux of blood and serous exudation, becomes swollen and 
hea^aer. The submucous cellular tissue, in the simple catarrh, re- 
mains intact ; in the chronic it increases in thickness, as does also the 
muscular coat. The black pigmentation of the solitary intestinal 
glands, which gives to the entire mucous membrane a grayish-black 
color, almost invariably seen in chronic intestinal catarrh of adults, 
never occurs in Jiurslings, nor in larger children, except faintly, al- 
though chronic diarrhoeas are usually extraordinarily protracted in the 
infant. The mesenteric glands are sometimes reddened, but never 
infiltrated and liypertrophied^ as in enteritis foUiculosa. 

Etiology. — The primary idiojoathio intestinal catarrh occurs in 
nurslings much less frequently than in artificially-reared children. In 
the former it is scarcely ever caused by the nutriment, mother's milk ; 
but, if the wet-nurse is unwell, suffers from diarrhoea, or is afflicted mth 
some mental trouble, restlessness, colic-pains, perhaps a very mild 
and transitory diarrhoea will attack the nursling, more or less mark- 
edly interfering with its development. Most frequently intestinal 
catarrh in nurslings originates from cold, or eruption of the incisors, as 
a result of swallowing large quantities of secreted saliva and mucus, 
and at the time of weaning (diarrhoea ablactatorum). In children 
brought up by hand, the nutriment is a prolific source of the most 



148 DISEASES or CniLDREX. 

rarpng diseases, particularly of diarrhoea. It has already been ob* 
served in the section on " Nutrition," that the casein of cow's milk 
curdles in the infantile stomach into large lumps, whereas that of wo- 
man's milk forms onl}'^ loose flakes, by which alone the great difference 
between the freshest and best cow's milk and the milk of a wet-nurse 
may be exj^lained. But in large cities, where the artificial rearing of 
children is of the greatest frequency, it is actually impossible to pro- 
cure fresh milk several times a day, and it is needless to mention the 
manifold adulterations of the milk. There is scarcely an artificially- 
brought-up child who has not suffered at least once, for a long time, 
from intestinal catarrh, and vras thereby retarded in its development 
for several months. 

In children over one year of age, the process of dentition is the 
most frequent cause. Even the physiological process, as is known, is 
accomjDanied by a moderate diarrhoea, which, however, may be aggra- 
vated and become the most profuse, cholera-like diarrhoea, and j^rove 
fatal in the course of twenty-four hours, or bring on an irremediable 
marasmus. 

On the other hand, diarrhoeas, in conseqvience of abnormal irritation 
of the food, are less frequent in children Avho have passed the first year 
of life, for the stomach is then more capable of digesting heavier arti- 
cles of diet. In summer, before the various kinds of fruit have attained 
a proper degree of ripeness, intestinal catarrh occurs among children 
of this age, epidemical^, and is usually liable to assume more of the 
character of dysentery, for, in addition to the numerous evacuations, the 
childi'en also suffer from colic-pains, obstinate tenesmus, and some- 
times also from l3loody stools. 

Symptoms. — In small children affected Avith diarrhoea, various 
changes may be observed even before the appearance of the principal 
s^-mptoms of this complaint. They become restless, cry almost un- 
ceasingly, draw up the tliighs, refuse the breast or sucking-bottle, in 
short, have the various symptoms of flatulence and colic. With the 
first watery or liqmd stool, if it is at all copious, almost all the symp- 
toms of colic disappear permanently, if the exciting cause of the diar- 
rhoea was only a temporary one, for example, a small quantity of 
sourish milk. This rapid subsidence, however, is seldom the case, it 
occurring almost only in children at the breast. Usually a single ad- 
ministration of sourish milk suffices to induce a severe intestinal 
catarrh that Avill last for weeks. The greater the extent of the sur- 
faces of the intestines affected with catarrh, the more profuse i^nll the 
diarrhoea l^e, the longer it will last, and the more severely will the nu- 
trition suffer from it. Catarrh of the small intestines causes scarcely 
anj' colic and but little diarrhoea, for the secretions that are then 



DISEASES OF THE DIGESTIVE APPARATUS. ^49 

poured out may in greater part be absorbed by the large intestines. 
Catarrh of the large intestines, on the contrary, and particularly of the 
rectum, is frequently combined with violent pains, with tenesmus, and 
with constant profuse diarrhoea. The color of the fseces in diarrhoea is 
normal at first, but with every evacuation it loses in tint, so that final- 
ly a very bright yellow, even gray, rice-water-like fluid, without any 
smell, is discharged. The retin-n of darker color and of odor to the 
f^ces may be looked upon as the most favorable sign of the speedy 
cessation of the diarrhoea. The abdomen is usually painful about the 
navel ; it is somewhat distended ; borborygmus is present ; the per- 
cussion-sound, when much fluid happens to be in the intestines, is in 
one place dull, and in another tympanitic. The secretion of urine is 
very much diminished ; it is very rich, comparatively, in pigmentary 
matter, and, if allowed to stand for several hours at a low temperature 
(under 54° F. at the least), will deposit a sediment of double urate of 
soda, the so-called brick-dust precipitate. The thirst is very great ; 
the peculiar circumstance is sometimes observed here, that the child 
refuses to take the breast diiring a severe attack of diarrhoea, but 
readily drinks sweetened water, or prefers pm-e cold water ; as soon, 
however, as the diarrhoea is checked, it will not touch any cold water, 
and returns to the breast with its former avidity. Artificially-fed chil 
di-en will take a few teaspoonfuls of broth to allay thirst, by which 
they are quieted for a short time, but very soon become all the more 
excited by the irritation caused by the newly-administered food ; from 
this excitement they do not recover for hours. When a child is so 
unfortunate as to be attended by persons who suppose that its rest- 
lessness can be allayed by feeding it, and will therefore rise several 
times in the night to prepare pap or porridge for it, though it may 
consume but a very few teaspoonfuls, we will never succeed in saving 
it from death, unless they can be convinced of their false views and 
pernicious practice. I, at least, have never yet been able to carry a 
child through, that was nursed by such attendants. 

At the invasion of a simple intestinal catarrh, the children have no 
febrile symptoms, such as dryness or increased temperature of the 
skin; on the contrary, when the diarrhoea is profuse and colorless, 
they soon become cold, the tip of the nose white and cold, the breath 
loses its natural warmth, the lips turn pale and bluish, as do the tips 
of the fingers, and the adipose tissue that fills up the orbits disap- 
pears extremely quickly, the eyeballs sink back into the orbits, and the 
expression of the countenance peculiar to these patients results. 
But after the diarrhoea has been arrested, fever usually comes on in 
consequence of the augmented metamorphosis of the tissues, in most 
cases lasting very long, retarding the recovery, and often leading to en- 
11 



150 DISEASES OF CHILDREN. 

teritis folliculosa and atrophy. When this fever of reaction is of short 
duration, a rapid recovery will ensue after its disappearance. The 
stools for some time will retain their abnormal quality, for they either 
become very hard or remain slimy, and then assume an offensive smell, 
the appetite returns again, and the children remain quiet after their 
meals ; this is the surest sign that the digestion again goes on with- 
out difficulty. 

The most frequent complication of this disease is catarrh of the 
stomach ; the vomiting, however, as a rule, ceases before the diarrhoea. 
Bronchitis complicates intestinal catarrh equally often. The prog- 
nosis assumes a most unfavorable aspect when the disease passes into 
enteritis folliculosa, which happens so frequently in artificially-reared 
children. 

Treatment. — In children at the breast, a mere dietetic treatment of 
the wet-nurse is usually sufficient. If she suffers from dyspepsia, with- 
out fever and intestinal catarrh, as is very frequently the case from 
emotional excitements, then her diet should be restricted for a few 
days ; she should only be allowed milk, soups, some coffee, meat-broths, 
and boiled fruits ; as a drink, almond-milk, Avine-and-water, or pure 
water. The secretion of milk from such a diet, so long as there is no 
continued fever present, is never arrested ; it is at the most somewhat 
diminished, but that is very beneficial to the nursling that suffers from 
diarrhoea. 

If a wet-niirse, through some error of diet, has contracted vomiting 
and diarrhoea, a stricter regimen will have to be instituted ; she should 
then get nothing but mucilaginous soups, wheat bread, and demulcent 
drinks, rice-water, gum-water, salep-water, or almond-milk ; and if, after 
two or three daj'^s of such a course of treatment, the diarrhoea is not 
arrested, then ten or twelve drops of laudanum are to be given to her 
immediately after nursing the child, and she should wait at least four 
hours before she puts the child to her breast. But if the diarrhoea 
nevertheless tends to run into a chronic form, and no benefit has ac- 
crued from the use of laudanum, then, while enforcing a strict diet, I 
desist from the further use of opium and give astringents, alum, tan- 
nin, Colombo, argent, nitr., etc. Medicine can seldom, if ever, accom- 
plish much in children at the breast, because most of them unwillingly 
take any thing fi-om a spoon, and spit the fluid out again that has been 
poured into the mouth. For these reasons, the pencilling of the mouth 
with laudanum is the most convenient and practical procedure. For 
this purpose, I use a camel's-hair brush ; dip it into laudanum, shake 
off the first drop by snapping it with the finger, and then introducing 
it into the mouth of the child, press the chin a little upward, and pull 
the brush out from between the compressed lips. In this manner 



DISEASES OF THE DIGESTIVE APPARATUS. 151 

about half a drop is left in the mouth, and, if two or three drops 
of water are dripped upon the tongue, the child will swallow all the 
fluid contents of its mouth without any delay. Usually a sleep of 
several hours' duration and an arrest of the diarrhoea follow upon this 
procedure. I have never observed from this application the bad effects, 
cerebral irritation, and cerebral congestion, which are said to ensue 
from opium, possibly from larger doses or from a long-continued use. 

Great benefit is derived, in children at the breast suffering from this 
disease, from small clysters of demulcent decoctions, barley infusion, for 
example, with one or two drops of laudanum. For the introduction 
of medicines into the rectum, which in order to become absorbed ought 
to remain there for several hours, the common children's syringes are 
much too large, and I have therefore for some time been in the habit 
of using small uterine or urethral tin syringes, which I apply myself 
after having them well oiled and warmed. Quantities of two or three 
drachms are almost always retained, and the action of the opium begins 
in from thirty to sixty minutes. 

Children brought up by hand suffer from a totally different kind of 
intestinal catarrh than those at the breast, for the exciting cause of the 
disease, the unsuitable nutriment, is not here a temporary one, but is 
continued for a long time and during the sickness. In general, the 
rule holds good that no child with intestinal catarrh tolerates cow's 
inilJc, whether pure or mixed with tea or boiled into a broth with meal 
or bread, and that the diarrhoea will only exceptionally be arrested if 
a milk-diet is persevered in. The first condition, therefore, is a total 
abstinence from cow's milk. As soon as liquid stools appear, the pa- 
tients shoxild only be allowed demulcent drinks, of which the best and 
most constipating is a decoction of salep, prepared fresh twice a day, 
by boiling as much powdered salep as can be taken up on a silver half- 
dime in ten ounces of water. In place of milk, the children may be 
allowed for their meals a thin mucilaginous beef-broth, vnth rice, 
barley, or groats, slightly sweetened with sugar ; it should, how- 
ever, be deprived of fat, and without salt. This diet is to be continued 
for twenty-four hours after the stools have acquired their normal con- 
sistence ; if the appetite has improved, a few teaspoonfuls of triturated 
wheat-bread may be boiled in the beef-broth. For further particulars, 
we refer the reader to the chapter on " Artificial Nutrition," p. 44. 
After the stools have been normal for at least two days, a trial may 
be made with one milk-pap each day, then Avith two, and finally three 
a dav, and the salep-water should be continued till it may appear 
proper to substitute it by the ordinary spring-water. 

The pencilling of the mouth with laudanum and the use of opiate 



152 DISEASES OF CHILDREN 

clysters stand at the head of all therapeutic measures. But occasion- 
ally, in the profuse diarrhoea of summer, opium proves inefficacious ; 
then small doses of calomel, gr. ^ three or four times daily, or a solu- 
tion of nitrate of silver (gr. ss. to water 3 iij), with the addition of one 
drop of laudanum, without any syrup, proves more effectual. Vege- 
table remedies containing tannic acid, such as Colombo, rhatany, 
pure tannic acid, and astringents in general, are with difficulty ad- 
ministered to small children, unless mixed with large quantities of 
syrup, and on that account are but seldom resorted to ; in older chil- 
dren, however, they may be often er employed. In some instances 
I have seen the diarrhoea checked by a solution of alum (gr. vj to 
mucilage 3 iij), though it was not possible to arrest it by any of the 
remedies just mentioned. The principal treatment will always be a 
proper prophylaxis. No cow's milk should ever be given to chil- 
dren, unless it is first rendered alkaline by adding a teaspoonful of 
a soda solution ( 3 j to water 3 vj) to it, as described in a previous 
chapter, and it will then become speedily evident that intestinal 
catarrhs may often be avoided, or, where they already exist, rendered 
less severe and protracted. Had I the choice, when compelled to 
treat an intestinal catarrh by the diet or by medicine only, I would 
prefer the dietetic treatment alone ; for I have often satisfactorily 
convinced myself of the utter inefficacy of all therapeutic reme- 
dies in the treatment of this disease when the child is sustained on 
a milk diet. 

[Recently that multiform and serious group of diseases charac- 
terized by frequent and profuse discharges from the bowels, vomit- 
ing, etc., occurring in this country most frequently during the sum- 
mer season, has been successfully treated by bromide of potassium, 
and numerous cases have been i-ecorded attesting its success. The 
theory is that, as these diseases are mostly due to nervous excita- 
bility and irritability of the mucous membranes, they are assuaged 
by the hypnotic action of the drug. Indeed, it would be difficult to 
mention any disease directly or indirectly connected with any of the 
nervous centres in which this remedy has not been used with reputed 
success. Again, this drug is employed in all those diseases depend- 
ing upon irritation of the terminal branches of the peripheral nerves, 
such as whooping-cough, spasm of the glottis, and affections of the 
alimentary canal generally. In the latter class of diseases, it is 
claimed that the remedy acts by " subduing the morbid irritability 
of the mucous surfaces, by its influence over functional disorders of 
the nervous centres." E. Moutard-Martin and others, however, 
assert that bromide of potassium is contraindieated in the diar- 
rhceal diseases of infancy. 

I cannot lay claim to any very great success with this remedy 



DISEASES OF THE DIGESTIVE APPARATUS. 153 

in diarrhoea! affections. In all affections of the nervous system it 
is of undoubted value, but in the gastro-intestinal of the nursling, 
attended by vomiting and profuse and frequent discharges from the 
bowels, I still give preference to the opium-treatment, administering 
the remedy by injections per rectum. I am certain that the mor- 
tality would be vastly less in this class of diseases if treatment by 
injections per rectum were more frequently resorted to than now. 
In many cases I have succeeded in controlling the dejections, the 
vomiting, and the tenesmus by injections of comparatively large 
doses of laudanum frequently repeated, where all other remedies and 
methods of treatment had failed. In one case, that of a child fifteen 
months old, who was apparently moribund, I administered an injec- 
tion containing ten drops of laudanum, and two hours thereafter I 
repeated the dose with the effect of restoring the pulse at the wrist 
and the natural color and warmth to the body. In another I achieved 
the same happy result by three injections, each containing eight 
drops of laudanum, and for three days, during which the stomach 
rejected everything, I sustained the little patient by injections of 
egg-nog and milk. I, however, never rely upon the nurse or rela- 
tions of the patient to administer the injections, but always attend 
to them myself. In the milder forms of diarrhoea the pulv. cretae 
com. of the Dispensatory and subcarbonate of bismuth are often of 
great benefit. The former, by its alkaline action, neutralizes the 
acidity of the intestinal tract. The bismuth may be given combined 
with small doses of Dover's powder.] 

(7.) Enteritis Folliculosa and Tabes Mesenteeica. — It is of 
great practical importance to carefully diagnose between simple in- 
testinal catarrh and enteritis folliculosa, although the anatomo-patho- 
logical differences are not very striking, and the transitions of that dis- 
ease into the one under consideration are of very frequent occurrence. 

Pathological Anatomy. — The submucous tissue is found mark- 
edly infiltrated, so that the bowel has percej^tibly increased in 
weight, and the signs of an acute intestinal catarrh are jaresent 
upon the entire mucous membrane of the large, and ui^on an extensive 
tract of the small intestines, i, e., instead of the normal cylindrical 
epithelium, none but mucous corpuscles are seen. The solitary glands 
and Peyer's patches are in some parts intensely swollen, and at the 
first glance are seen to project like white nodules above the level of 
the mucous membrane ; in other parts, however, they are already 
ruptured, and then represent empty, minute, crater-like excavations. 
These excavations occur upon the summits of the elevations origi- 
nally j)roduced by the swelling of the follicles. The mesentery is in- 
jected and turgid, the chylopoetic vessels are plethoric, and of a pink 
color ; the mesenteric glands in those regions corresponding to the in- 



154 DISEASES or CHILDREN. 

testinal catarrh are increased in size from two to four fold ; in recent 
cases, when cut into, the incised surface presents a rose-color, 
but, when of longer duration, a yellowish-white color. The micro- 
scopic elements are the same as in the normal mesenteric glands, but 
when the color is yellowish and the gland has increased in hardness, 
the connective tissue will be found to predominate. Here, too, as in 
simple intestinal catarrh, notwithstanding the long existence of the 
diarrhoea, remarkably little pigmentation of the mucous membrane 
is found. The essential anatomo-pathological difference between in- 
testinal catarrh and enteritis folHculosa consists in the cu'cumstance 
that in the latter the mesenteric glands participate in the disease. It 
is much to be regretted that neither by injections nor in any other 
manner can it be experimentally proven that the absorption of the 
chjle is hindered by these hypertrophied mesenteric glands, and 
thereby the nutrition and progressive development of the child inter- 
fered with. But, when in an atrophied child, whose condition was ori- 
ginally induced by enteritis foUiculosa, no changes but those indurated 
and hypertrophied mesenteric glands are found, the supposition be- 
comes very probable, that the passage of the chyle has been mechan- 
ically interrupted, and thus the children, although they have con- 
sumed an enormous quantity of food, and have had no diarrhoea for 
weeks preceding death, have nevertheless languished to a certain ex- 
tent for want of a sufficient supply of chyle. The term tabes mesente- 
rica of the older physicians is therefore by no means so incorrectly 
founded and obsolete as some of the later writers are inclined to rep- 
resent it. The older erred only in this, that they thought they could 
feel the enlarged glands. In this glandular hypertrophy the intes- 
tines always become tympanitic and distended, and then it is alto- 
gether impossible to feel these small tumors, which scarcely ever 
attain to the size of a hazel-nut, between or beneath the tense bowels. 
At any rate, they must be forcibly comjDressed against the vertebral 
column, if it is desired to feel them. 

In instances of develojyed tuberculosis of the mesenteric glands, as 
it sometimes occurs in children several years old, the firm, hard, soli- 
tary tubercles may indeed be felt through the abdominal walls. But 
these are larger glands agglomerated into patches or masses, and 
traversed by deposits of cheesy tubercle. Such slight enlargement as 
is observed in enteritis folliculosa can never be detected during life 
by the sense of touch. 

Symptoms. — Enteritis folliculosa always begins with intestinal 
catarrh, and consequently we may refer the student to the symp- 
toms of that disease given in the preceding section. But, instead 
of the stools becoming semisolid in a few days, and the nutrition 



DISEASES OF THE DIGESTIVE APPARATUS. 155 

regulated as in simple intestinal catarrh, tliey remain perfectly liquid 
and assume a putrid, foul odor, erode the anus and its adjacent parts, 
the inner surfaces of the thighs, and even the heels, which are 
brought in contact with the anus by contractions of the thighs and 
legs. An intense continuous fever becomes superadded, and the 
patients have a constant and severe thirst. The tongue is red and 
smooth, or coated with a white fur, and in the latter stages of the dis- 
ease almost always affected with thrush. Vomiting is frequent, but 
not present in all cases. Rapid emaciation is characteristic of the 
disease. In previously perfectly-healthy, well-nourished children, 
small wrinkles are soon observable on the inner surfaces of the thighs ; 
and the adipose tissue, that was previously firm and solid, is now 
felt to be soft and flabby. Under the continuation of this putrid diar- 
rhoeal discharge emaciation progresses so rapidly that, at the end 
of a few days, the bones of the hands and feet plainly show their 
outlines, and the integument on the thighs forms loose, flabby 
folds. On both sides, a collection of inguinal glands may now be 
detected, which also swell up to twice or thrice their normal size. 
The eyes are sunken, a deep fold forms from the inner angles to 
the zygomatic arches, the cheeks become pale and flabby, the con- 
tours of the masseters distinguishable, the chin pointed, the neck 
wrinkled, the sterno-cleido-mastoidei muscles and larynx promi- 
nent, the ribs can be counted without being touched, and the verte- 
bral column and bones of the pelvis are covered by an atrophic skin 
only. 

A very peculiar phenomenon may be observed on the occiput. 
The superior border of the occipital bone shoves itself beneath the 
parietal bones, thus forming a step, the upper plane of which is 
formed by the parietal bones, and the lower by the occipital bone. 
Exceptionally the occipital glides over the parietal bones. A sim- 
ilar but less striking displacement takes place at the frontal bones, 
the superior borders of which slide beneath the parietal. The dimi- 
nution of the cavity of the skull is caused by a decrease in the size 
of the brain, for this organ participates in the general atrophy, and, 
since it consists in greater part of fat, it must, therefore, also suffer 
a decided loss of this material. So far as I am aware, there is no 
quantitative chemical analysis of the brains of atrophic children to 
be found, it is only known that the brains of young children in 
general are poorer in fat than those of the adult ; such an investiga- 
tion is really a desirable one, and for which the Pisdiatria should 
call upon pathological chemistry. If the bones of the cranium have 
once overridden each other, and cerebral atrophy has become super- 
added, an improvement is only to be looked for in the rarest in- 



156 DISEASES OF CniLDREN. 

stances ; the patients almost always waste away more and more, and 
invariably perish, although they may have had no diarrhosa for weeks, 
the stools, however, retain a putrid odor, and the appetite remains to 
the last. From this atrophy of the brain (to be hereafter considered 
under the heading of Hydrocephaloid Disease) a long train of cere- 
bral symptoms results. We find in the abdominal integument one 
of the best indices as to the degree to which the atrophy has reached. 
If, pinched and raised into a fold, it remains for some time after the 
fingers are removed, the prognosis is always, and under all circum- 
stances, to be regarded as most unfavorable ; the prospect of recovery 
always improves in proportion to the rapidity with which a fold of 
the integument thus produced disappears. 

In atrophic children with tympanitic abdomen — a condition Avhich, 
in fact, is usually present in atrophy, as a result of enteritis folhculosa 
— small solitary tubercles of the size of pins' heads are seen upon the 
abdominal integument, united to each other by very fine cords, and 
only recognizable by the feel. These cords are not plugged-up veins, 
because veins, when the integument is so atrophied, and in such a 
superficial position, would appear bluish or black. They can only be 
obliterated veins, or, what is still more probable, lymjDhatic vessels — 
a supposition which may serve to explain the character of the small 
nodules. 

Treatment. — Every thing that has been mentioned in connection 
with catarrhus intestinalis is applicable to the treatment of this dis- 
ease, as an effect of which, the infiltration of the mesenteric glands 
may be regarded. As a rule, all methods of treatment are ineffica- 
cious. There is one remedy, however, from which I have seen some 
very striking, favorable effects, namely, mother's milk. Atrophied 
children, after four or even six months' disease, already at the brink 
of the grave, suffering from putrid diarrhoea, a thrush-covered tongue, 
and in incessant restlessness from pain, or tearing their faces with 
their long, lean fingers, when put to the breast of a mother, are changed 
as if by magic. At first they suck only for a few seconds, and then 
relapse again into their habitual restlessness, but, after a few days, 
nurse like healthy cliildren, and sleep for several hours at a time ; the 
evacuations become yeUow, their odor normally sour ; and they regain 
flesh and strength so rapidly that they can scarcely be recognized 
after a few weeks. Where the circumstances are such as to preclude 
the possibility of procuring a wet-nurse, the prognosis, as already 
said, is fere lethalis. In such cases I have several times succeeded in 
reducing the temperature of the skin by the use of cinchona, gr. j, 
twice daily. The atrophy also diminished, and, under an extremely 
cautious, laborious feeding, the children finally began to thrive. As 
an after-treatment, IJ . mart, pomat., ten drops three times daily, is 



DISEASES OF THE DIGESTIVE APPARATUS. 15 7 

to be given for a long time. This treatment, however, generally 
fails, the temperature of the skin is diminished for only a short 
time, the patients sink little by little, till finally, often after many 
weeks of suffering, they are relieved by death. 

(8.) Dysentery — the Flux. — In great epidemics of dysentery 
— such as are especially malignant in swampy regions and in the 
tropics — children under one year of age are almost totally exempt. 
A few instances are recorded, however, of women who, while suffer- 
ing from flux, gave birth to children that immediately after birth 
perished of dysentery. Older children, particularly after the second 
dentition, are as liable to it as adults. Sporadic dysentery, on the 
other hand, frequently occurs in infants, but, on account of its mild 
course, is not usually particularly watched. 

Symptoms. — The symptoms of sporadic and epidemic dysentery 
may very properly be treated of together, it being only necessary to 
observe here that the sporadic form never exhibits the intense and 
dangerous character of the epidemic disease. At first there is sim- 
ple diarrhoea, which may last for several days without giving rise 
to any special symptoms, till the specific stools of dysentery appear, 
accompanied by an increase of colic and tenesmus. 

The best index of the condition of the intestinal mucous mem- 
brane is always obtained from a careful inspection of the stools. 
Every stool which contains a glairy mucus, formed into lumps, in- 
dicates a morbid alteration of the mucous membrane of the large 
intestines, or, at least, of their follicular apparatus. With this glairy 
mucus, resembling granules of boiled starch, a few streaks of blood 
soon become associated, or the whole stool becomes uniformly 
bloody, according as the bleeding occurs near to or far from the 
anus. As this mucus increases, the proper fecal masses constantly 
grow less and less, and finally lumps of mucus, with only an admix- 
ture of faeces, are evacuated. There is, generally, no great difliculty 
in recognizing the blood that has become mixed with the alvine 
discharges ; if streaks and small lumps of blood are present, it will 
be appai'ent at a glance, and, even when the blood has been for a 
long time in contact with the mucus, a part of the blood and mucus 
will become thoroughly mixed with each other, and then they will 
give to the whole evacuation a pink or an actually red color. In 
fact, this discoloration alone suflices to convince us of the presence 
of blood, because no other substance giving this color occurs in the 
fseces. All doubts as to the presence of blood in the stools may be 
easily decided by the microscope. 

If ulcers form, which scarcely ever happens in sporadic flux, 
the evacuations assume a dirty-gray or grayish-red color, and a 
putrid odor, on account of sloughed mucous membrane, and large 



158 DISEASES OF CHILDREN. 

quantities of pus discharged from the ulcers becoming mixed with 
them. The exfoliation of large patches of mucous membrane, said 
to have been frequently observed in tropical dysenteries, I have 
never observed in this country. Occasionally firmer lumps of loamy 
fteces, wrapped up in purulent or bloody mucus, pass off, although 
the rest of the symptoms do not by any means indicate that the dis- 
ease is about to be checked. These clayey lumps are, most probably, 
derived fi-om some part of the small intestines not affected with dys- 
entery. This condition does not by any means improve the prognosis. 
For immediately after the discharge of these faeces, which deceptively 
indicate an amelioration of the disease, the previous state of the alvine 
evacuations reappears. 

A red and a white flux, according as to whether blood is or is not 
mixed with the stools, has been spoken of — a classification which 
naturally dispenses with aU scientific basis, for it is very possible, 
indeed, for a child to have the white flux on the first day, the red 
on the second, and the white on the third or fourth again. When 
improvement actually takes place, the discharges will first assume a 
fecal odor, subsequently the normal consistency, and the muco-pu- 
rulent character gradually disappears. Round worms, when present, 
are invariably expelled with the dysenteric faeces. At the invasion 
of the disease the stools have a fecal odor, and this odor returns Avhen 
the child progresses toward recovery ; at the climax of the complaint 
the normal odor has wholly disappeared, or it is soin-ish and un- 
healthy. In the epidemic flux, when pus and pieces of sloughed mu- 
cous membrane are ejected, the stools become intensely pungent and 
putrid, resembling sulphxu-etted hydrogen. Microscopical examination 
reveals mucous-corpuscles, epithelium-cells, blood-corpuscles, large ag- 
gregations of oil-globules, some particles of food, villi, and triple 
phosphates — all embedded in a molecular, finely-granular mass, whose 
chemical reaction is usually alkaline. Albumen may be demonstrated 
to be present by diluting and agitating the stools with distilled water, 
and then filtering the liquid, and subjecting it to the appropriate 
tests. The stools vary in number exceedingly. In the milder forms, 
four to eight ; in the severer, twenty to thirty passages take place in 
the twenty-four hours, the number depending less upon the quantity 
to be evacuated, for that is often very slight, than upon the degree 
of tenesmus. 

Abdominal pains and tenesmus are never absent / the pain is 
mostly paroxj^smal, but, at the climax of epidemic dysentery, children 
moan unceasingly. Touching any part of the abdomen, near the 
navel, or over the course of the colon, produces pain. The tenesmus is 
very tormenting ; the lower folds of the rectum are frequently seen to 



DISEASES OF THE DIGESTIVE APPARATUS. 159 

protrude, presenting a livid-red color, and, notwithstanding tlie violent 
efforts at expulsion, scarcely a teaspoonful of mucus can be discharged. 
Prolapsus of the rectum is a frequent result of this straining. The use 
of clysters, which in dysentery has the most beneficial effect, is by 
this tenesmus rendered very difficult and often impossible. Nervous 
children are often attacked by convulsions in consequence of the aggra- 
vated pains caused by the introduction of the injection-pipe. Tenes- 
mus usually comes on with the first mucous evacuation, and remains 
throughout the disease. If the disease continues to grow worse, pa- 
ralysis of the rectum may ensue, relieving the tenesmus, but rendering 
the prognosis extremely unfavorable. 

In epidemic flux, vomiting sometimes occurs, and, if persistent, is 
a sign of commencing peritonitis. In sporadic dysentery it is only 
very exceptionally observed. 

ITo fever is usually present at first ; it appears in the course of 
the morbid alterations of the intestines. The pulse supplies no index 
whatever to the severity and extent of the lesions. The temperature 
of the skin is seldom increased ; it is usually normal, in grave cases 
even diminished. Delirium and convulsions come on tolerably often 
in nervous children, even in sporadic dysentery. 

The secondary morbid conditions of sporadic flux that should be 
mentioned are lobular pneumonia and tabes mesenterica, with infil- 
tration of the mesenteric glands. In connection with epidemic dys- 
entery, antemia, pyaemia, marasmus, intestinal perforations, peritoni- 
tis, strictures of the intestines, icterus, and hepatic abscesses, deserve 
consideration. In the sporadic form recovery may take place in from 
four to six days, in the epidemic in ten to fourteen. The emaciation 
attendant upon this disease is very great ; many children succumb 
to the sequelae who have escaped the disease. Death may take place 
either during the first few days of the disease or in the chronic stage. 

Epidemic dysentery is known to become complicated with all pos- 
sible acute and chronic affections. The sporadic principally attacks 
children in the first dentition, and older ones in the hot summer 
months, at the season of unripe fruits. 

Pathological Anatomy. — The dysenteric exudation is only found 
in the large intestines and rectum, more particularly upon the summit 
of the folds, at the flexures of the bowel, and is seen as a dirty-white, 
yellowish-gray, grayish-red, or dark-colored layer, which often attains 
to the thickness of a line, and may be easily stripped off. The mucous 
membrane beneath it is reddened, softened, and swollen ; the internal 
surfaces of the bowel present an uneven ap23earance. Within the in- 
testines, the dysenteric mucus and the feculent masses are found. 
A.fter several days this mucous membrane is cast ofi" in fragments, and 



160 DISEASES OF CHILDREX. 

superficial or deep ulcers, with prolonged points and indentations, 
now make tlieir appearance. The solitary follicles are always SAvollen, 
if not ulcerated. In the rest of the organs the signs of anaemia are 
found, but the peritonaeum, especially the parts corresponding to the 
morbid lesions in the mucous membrane, is injected. In sporadic 
flux, extensive or deep ulcers are very rare. 

Treatment. — Uniform warmth in a weU-ventilated room and spare 
diet are indispensable measures in the treatment. Cold drinks aggra- 
vate the pains, and therefore every thing administered should be luke- 
warm. It is best to give the children nothing but mucilaginous 
broths and demulcent drinks ; those at the breast bear very well the 
wet-nurse's milk ; in artificially-reared children cow's milk produces 
\dolent pain, and for this reason should not be administered. Opium 
is the sovereign remedy in dysentery, and the safest method of apply- 
ing it is in the form of clysters, but in this, unfortunately, we are 
often interfered with by the tenesmus. In such cases the pencilling 
of the mouth with laudanum, spoken of in the treatment of intestinal 
catarrh, will then have to be resorted to. I, however, never yield to 
the assurance on the part of the attendant that it was not possible to 
inject the medicine, but always try myself to administer the clyster, 
which I usually make of a drachm or two of some mucilaginous sub- 
stance, with one drop of laudanum, and I often succeed in it, although 
the existing circumstances were not encouraging. Very good effects 
are also derived from the combination of calomel and opi \m. For 
example, to a cliild one year old, I give the following : 

5 . Calomel gr. -J-, 
Op. pur. gr. ^, 
Sach. alb. gr. v, 
Dent. tal. dos. n. viii, 
S. one powder every two hours. 

Vegetable astringents, nitrate of silver, and alum, are useful only 
after the pains have been mitigated, and in the chronic stage. 

(9.) InttjsstTsceptions. — By intussusception, or invagination of the 
intestines (also called volvulus), we understand a slipping of one piece 
of the bowel into another, after the manner that the finger of a glove 
is reflected upon itself and shortened in pulling oS" a tightly-fitting 
glove. 

Pathological Anatomy. — Not all invaginations, by any means, 
which are found in the infantile cadavers, were diseased conditions dur- 
ing life ; most of them indeed, having occurred in the agonies of death, 
show no trace of inflammatory reaction, may be disengaged with the 
greatest ease, and may be seen in many places at the same time ; but 



DISEASES OF THE DIGESTIVE APPARATUS. 161 

tnese occur only in the small intestines. Singularly enough, they are 
found only in perfectly healthy intestines, not in the autopsies of chol- 
era, flux, typhus fever, or peritonitis, although they are seen also in 
children who have succumbed to cerebral diseases, and seem to be the 
effects of an unequal innervation of the muscular coat of the intestines, 
M^hich manifests itself preeminently in articulo mortis. However, there 
is also a long list of instances where, even in children under one year 
of age, invagination, with all its results — intestinal stenosis, intestinal 
haemorrhage, stercoraceous vomiting, rapid collapse, etc. — occurred, 
and as a rule terminated in death. The pathological displacement of 
the piece of the bowel is the same in both kinds of invagination. 

Every invagination consists of three continuous portions, lying 
upon each other, of which the outer and middle have their mucous sur- 
faces, the middle and inner their peritoneal surface's, in contact, as may 
be readily seen from the accurate drawing, PI. III., Fig. 3 B. The ex- 
ternal layer, or wall, c c, B,oMtansky calls the sheath, or the intus- 
suscipiens; the innermost one, a a, the advancing; the middle, 5 5, the 
protruding tube, and both together the intussusceptum. Between the 
advancing and protruding tube the flexed, conically-folded transverse 
section of the intussusception is found, which exercises a particular in- 
fluence upon the shape of the invagination. The dragging of the mes- 
entery serves to explain the reason why the invaginated intestinal 
piece never runs perfectly parallel into its sheath, but always presents 
a curve, and of its orifice not lying in the axis or centre of the sheath, 
but always eccentric, because it follows the course of the mesentery 
inflected along with it, and for this reason also the orifice of the intus- 
susceptum (c?) is never round, but distorted into a slit. 

The enlargement of the invagination is brought about by the 
mouth of the volvnlus {d) forming the fixed point, while the sheath 
at c c invaginates itself more and more. 

The cause of a volvulus is difficult to explain ; the intruding intes- 
tinal piece is probably more strongly contracted and has a more active 
peristaltic action than the wider, overlapping piece of the bowel. 
This circumstance seems to be sustained by the fact that the process 
is almost always preceded by protracted diarrhoea, by which the over- 
lapping portion is probably catarrhally weakened, while the intruding 
portion has a normal mucous membrane and acts normally. 

As infallible effects of invagination, we have disturbances of the 
circulation in the invaginated mesentery, oedema, and hyperemia of 
the invaginated gut, and inflammation and plastic exudation upon 
the peritoneal covering of the prolapsed and overlapping tube {a and 
b b). The oedema and inflammation of the invaginated portion may 
attain to such a degree, that the calibre of the intruding tube, at first 



162 DISEASES OF CHILDRExV. 

still pervious, becomes completely occluded, and then no alvine matter, 
but bloody mucus only, will pass off per anum, and stercoraceous 
vomiting will take place. 

Generally tlie invagination takes place from above downward ; it 
frequently occurs in the large intestines, and when in the rectum may 
possibly be felt per anum. 

Intussusception proves fatal either from the peritonitis spreading 
over the entire intestines, or from gangrene of the invaginated piece. 

S3niiptonis. — While the calibre of the gut is still incompletely 
closed, the symptoms will not be particularly characteristic, but when 
total stenosis has once taken place, then the well-known signs, as in 
strangulated hernia, supervene. The invagination of the gut by itself, 
even without total constriction, always gives rise to the most violent 
colic-pains, conjoined with which the abdomen soon becomes tym- 
panitic. In some instances, an oblong tumor may be felt, which is 
regarded by many authors as the invaginated portion of the bowel, 
but it much more probably consists of alvine masses, which have be- 
come arrested at the volvulus. The patients are generally consti- 
pated, although diarrhoea may also occur, and in man}" cases large or 
small quantities of blood may pass with the stools. The latter may 
be looked upon as the most constant and pathognomonic sign of the 
complete form of the condition. The vomiting of every thing par- 
taken of is almost equally constant, attended, sooner or later, by 
a yellow or greenish gastric mucus. The patients sink quickly into 
a state of collapse, with an expression very much like that of 
cholera patients, and death, as a rule, takes j^lace on the third or 
fourth day. 

A favorable but very rare termination is in general adhesions of 
the invaginated portions of the bowel, and subsequent sloughing off 
of the gangrenous piece. Some authors assert that the symptoms 
occasionally abate, even without gangjene and sloughing of the con- 
stricted portion, that the calibre of the gut increases, and the inva- 
gination may thus remain fixed. In that case, however, the canal is 
ever afterward constricted, presenting a more or less permanent 
obstacle to the passage of its contents. A chronic, relapsing state of 
inflammatory swelling is the result of this condition, which may 
readily develop itself into enteritis and cause new intussusceptions. 

Treatment. — The theoretic suggestions of Rohitansky to try in- 
jections by air or aspirations by means of a suction-pump, before the 
volvulus has become firmly fixed by exudation, wiU always remain 
theoretic. All remedies which cause an increased peristaltic action 
may do as much harm as good, for although the volvulus may, it is 
true, possibly become disengaged, yet in the reverse motions it may 



DISEASES OF THE DIGESTIVE APPARATUS. 163 

also become much aggravated, and a commencing and fortunate ag- 
glutination may thus be torn apart and interrupted. For the same 
reason neither mild nor drastic cathartics should be given, and still 
less emetics. The renowned application of mercurius vivus is at 
least harmless and often proves useful ; for the diminishing, con 
striated calibre of the oedematous invaginated gut may be thereby 
mechanically rendered a little pervious. 

The most rational treatment seems to me that suggested by 
Pfeufer, and often already successfully carried out. It consists in ab- 
solute rest, strict diet, and in the production of narcotism hy opium 
so as to effect a complete arrest of the peristaltic action, while ag- 
glutination takes place all around. Laparotomy has also been suc- 
cessfully performed for the relief of this affection, notwithstanding its 
very great dangers. 

(10.) IisrGrns'AL Hekin^ia {Hernia Inguinalis), — Since umbilical 
hernia has already been treated of on p. 65 in connection with the 
diseases of the navel, and since crural herniie in children hardly ever 
occur, it only remains for us to speak of inguinal hernia. 

Inguinal hernije in children are, in the great majority of instances, 
external and generally congenital, though not congenital in the strict 
sense of the term, but acquired in the first few days of life, by the 
early action of the abdominal muscular pressure. One or several 
knuckles of intestine may be forced through the still open processus 
vaginalis peritonei into the scrotum in the male, and the labiaa ma- 
joris in the female. The prolapsed viscera lie in contact with the free 
surface of the testicle, a condition not seen in any acquired hernia. 

An oval, not strictly circumscribed, soft, compressible tumor is 
found in the groin, reaching from the external ring into the scrotum, 
which, by a uniform, slightly rotatory pressure, may be removed with- 
out any difficulty. It is not easy to distinguish the testicle, but on 
very careful examination it will be found to lie above and behind the 
tumor. Flatulence, pressure of straining at stool, crying, and cough- 
ing, reproduce the replaced rupture. In girls, where the rupture is 
called " external labial hernia," one or the other labia majoris exhibits 
a soft, oblong tumor, which, though presenting similar characteristics 
to the congenital inguinal hernia of the male, never becomes so large, 
and is less frequently met with. Here the rupture originates by a 
portion of the intestines, or in very rare instances the ovary, forcing 
itself into the inguinal canal {canalis ligamenti rotundi) destined in 
the female foetus for the passage of the round ligament, which is open 
at its origin, but which before birth usually becomes closed through- 
out. According to V. Ammon, a distinct peritoneal fold rarely forms 
the covering for the hernial sac in this rupture. 



164 DISEASES OF CHILDREN. 

The contents of congenital inguinal hernia almost always consist 
of one or several knuckles of intestine, very rarely of omentum. At 
first the rupture is small, of the size of a pea, but soon grows larger 
and protrudes into the scrotum, inducing shortening and straighten- 
ing of the canalis vaginalis. Sometimes some serous fluid is effused, 
and then we have a hydrocele superadded to the inguinal hernia. Vio- 
lent attempts at reduction, perhaps, also may be a cause of inflamma- 
tory and even plastic exudation, in these cases producing filamentous 
adhesions between the prolaj^sed intestines and the testicle, when of 
course it becomes totally impossible to reposit the hernia. Strangu- 
lations, however, are extremely rare ; yet, when such a rupture tem- 
porarily becomes hard, painful, and apparently irreducible, by the aid 
of a warm bath, or still more easily by the aid of chloroform, reduc- 
tion may invariably be accomplished. 

If the rupture has already acquired a considerable size, and the va- 
ginal canal has become considerably distended, it will protrude again 
immediately after it has been reduced, and will only remain in the 
peritoneal cavity so long as the child is in the horizontal posture. 
These children are extremely liable to become excoriated, and it is 
as difficult to prevent the integumentary abrasions as to cure them. 
In the examination of a young child for inguinal hernia, the testicle 
should first be found, because a testicle that has but just passed 
through the internal abdominal ring, in a case of retarded descensus 
testiculi, represents a tumor analogous to a commencing hernia. As 
features distinguishing this condition from hydrocele, we may men- 
tion the reducibility of the tumor, in many instances attended with 
a gurgling noise, the absence of transparency, and the absence of 
fluctuation. The examination is carried out in this manner : The 
child is laid upon its back, an effort is carefully made to reduce the 
tumor, and, when that has been accomplished, the little finger is in- 
vaginated in the scrotum. It is next passed on upward toward the 
ring, the aperture is sought for, and, when found, its position and ex- 
tent are ascertained %vith the utmost ease. 

If we take a final resume of the most important varieties of con 
genital inguinal hernia, we find — 

In respect to the time of origin : 

(1.) Hernia canalis vaginalis congenita (rarer form). 

(2.) Hernia canalis vaginalis tnox post-partmn acquisita (more 
U'equent form). 

In respect to the difference of the sex : 

In boys : 

(1.) Hernia canalis vaginalis testiculi congenita. 

In girls • 



DISEASES OF THE DIGESTIVE APPARATUS. 165 

(2.) Hernia canalis ligamenti rotundi congenita. 

In respect to the complications : 

(1.) Hernia inguinalis congenita cum hydrocele. 

(2.) Hernia inguinalis congenita cum, adhcesione testiculi ad hv- 
testina. 

Treatment. — Most of tlie inguinal liernise disappear spontaneously 
without truss or bandage. This is effected by the best and simplest 
of all compression of the inguinal canal, viz., by the augmentation of 
the adipose tissues in the child. Good nutrition, attention to the 
bowels, and the avoidance of too great and lasting restlessness, suf- 
fice, as a rule, to cure this defect. If the precaution is only taken to 
reduce the hernia while the child is asleep, it will be of little conse- 
quence if it is prolapsed for the rest of the day. The reduction is 
very easily accomplished by the nurse, at the time the child is being 
put asleep, by pressing her hand firmly, but gently, over the tumor. 

I have only seen good effects from the use of trusses in children 
over one year of age. In very young children it is extremely difficult 
to apply the truss, and in many instances it is injurious. In the first 
place it is necessary to have three trusses, in order to have a dry truss 
every time one gets soiled and wet from the fseces and urine ; and, be- 
sides, if the child thrives, the old trusses in eight to ten weeks will be 
found to have become too small and useless, and must be replaced 
by three new ones, thus, perhaps, requiring a dozen. Furthermore, 
it is almost impossible to protect the child from becoming excoriated, 
and the parts that have once become chafed require several days to 
get well, leaving a new epidermis, which is usually soon destroyed 
again when the pressure of the truss is reapplied. Lead and zinc 
ointments, as well as repeated washings with cold water, or with wa- 
ter and brandy, do, indeed, seem to have a favorable influence in ren- 
dering the skin less prone to abrasion, but they rarely prevent it al- 
together. In lean children it is totally impossible to apply the truss, 
because it can never be properly secured. Wlien, therefore, appre- 
hensive parents absolutely desire a truss to be applied, they should 
be previously admonished of its great expense, and of the probable 
bad effects which result from its use. I usually cover the hernije with 
a piece of adhesive plaster, or order some harmless ointment to be 
rubbed in upon them, and insist, in addition, upon the utmost cleanli- 
ness, good attention, proper food, and see that the bowels act regu- 
larly. By these means I have already seen many children cured. 
The more rapidly the deposit of adipose tissue takes place in the child, 
the more surciy will the hernia be retracted, and permanent closure 
of the vaginal canal secured. 

(il.) FissTJRA Ani. — Nurslings and children of all ages suffer 
12 



166 DISEASES OF CHILDREN. 

sometimes from intense pain about the anus, which comes on at every 
attempt at defecation, and is due to a small fissure of the anus. 
Children so affected are always constipated, and the fissure has prob- 
ably originated from the violent efforts of pressing out the hard faeces. 
Now and then the firm, dry faeces are stained with blood, and, after 
defecation, a few drops of blood floAV from the fissure, which is so 
painful to the child that it screams aloud. It is necessary to observe 
that these rents of the anus cannot be seen by a superficial inspec- 
tion ; so that, in order to discover them, it is necessary to thoroughly 
separate the nates, and to examine fold after fold of the mucous mem- 
brane. They are very small, sometimes not more than from one to three 
millimetres in length, and differ but little in color from the rest of the 
reddened mucous membrane of the anus. The pains come on almost 
always during, and directly after, defecation, but seem to be very se- 
vere, if we may judge from distorted features, a general trembling, 
and reflex movements of the whole body of the child. 

Treatment. — It is necessary, first of aU, to relieve the constipation, 
which is best accoinplished by the administration of a half to a whole 
teaspoonful of the watery extract of rhubarb. The method advocated 
by Trousseau, of gi^^ng clj^sters containing 3j of ext. rhatany, I 
have not found satisfactory, as the introduction of the clyster itself 
causes the most intense pain. I cauterize these fissures with lunar- 
caustic, which is also tolerably painful, but it is only required once, 
whereas those clysters have to be repeated frequently, I also pay 
special attention to the bowels, with a view to prevent the faeces from 
becoming hard, Diarrhcea, also, ought not to be neglected in this 
affection, for the diarrhoeal discharges likewise hinder the healing: of 
the fissures, 

(12.) Polypi of the Rectum. — These polypi occur but very 
rarely, though they are perhaps sometimes overlooked. The record- 
ed cases of this affection in children have occurred in those who have 
passed the second year of life. 

A small and at other times a larger amount of hn?morrhage from 
the rectum, either with, or immediately after, defecation, is the prin- 
cipal symptom. In girls, who are near the age of puberty, this is 
readily misinterpreted for commencing menstruation. But the men- 
strual stains may be easily distinguished from those produced by 
haemorrhage from the rectum, by the circumstance that the former are 
almost always to be found on the anterior part of the linen, while the 
latter are almost exclusively confined to the posterior part. 

The evacuation of the fiBces is always painful and difficult, the 
polypus during that act occasionally protruding through the anal 
opening, but quickly retracting when the straining ceases. In explor- 



DISEASES OF THE DIGESTIVE APPARATUS. IQ^ 

iug the rectum by the finger, a painful operation, the polypus is felt 
to be situated very near the anus. This malady has, in the majority 
of cases, a tendency to spontaneous cure, resulting from the polypus 
becoming more and more pediculated, and finally torn off during a 
difficult defecation. The polypus is usually of the mucous variety. 

Treatment. — The removal of the polypus is readily accomplished, 
if, directly after a defecation — when it descends outside the anus — it 
is caught and pinched off with the finger-nails, or its pedicle tied. In 
order not to have to wait too long for an evacuation, a dose of senna, 
or some other cathartic, may be administered to the child a few hours 
before the appointed time for the operation, because, by the tenesmus 
thus produced, the polypus v/ill most certainly be protruded, and will 
remain out an unusual time. 

(13.) Prolapsus Ani. — Two conditions are described under the 
name of prolapsus of the anus, differing considerably from each other, 
namely (1), a simple protrusion of the lower folds of the mucous 
membrane, and (2), an invagination of the upper part of the rectum 
into the anus, which makes its appearance external to the anus. 

The rectum, as is known, may be divided into three portions, an 
upper, middle, and lower (PI. III., Fig. 4, a, h, c). The upper por- 
tion joins the sigmoid flexure, and, hke it, is covered by peritonaeum, 
has a cylindrical form, and runs from above downward, and slightly 
from left to right. This portion forms almost half of the entire rec- 
tum, and extends from its junction with the sigmoid flexure to a 
line where the peritoneal covering ceases (PL III,, Fig. 4, No. 3). 
Posteriorly the rectum loses this covering higher up than it does an- 
teriorly, where it is continued to a point opposite the third sacral 
vertebra. The middle portion (b) begins where the peritonaeum 
leaves the rectum, and where it is adherent to the sacrum by loose 
cellular tissue onlj^, and joins the bladder and prostate in the male, 
and the vagina in the female. This portion is remarkable for the 
strength of its longitudinal fibres, while its circular and transverse 
are but imperfectly developed. In constipation, it may become enor- 
mously distended, and harbor large quantities of hard, feculent mat- 
ter. The third portion (c) is the shortest ; it reaches from the pros- 
tate gland downward to the anus, and possesses a thick layer of trans- 
verse muscular fibres, the two sphincters ani. 

Either this sphincter, or lowest part of the rectum, may become 
simply everted, and present a bluish-red or pink colored puffy mass 
with a central opening, or the middle section of the rectum (b) may 
become invaginated in the lower and hang down from the anus, a 
pink-colored or li\'id mass several inches in length, the color depend- 
hig upon the degree of its constriction by the sphincter. A simui- 



168 DISEASES OF CHILDREN. 

taneous eversion of the sphincter portion and invagination of the 
middle portion do not seem to happen. In the simple eversion of the 
sphincter portion, the examining finger may force its way into the 
central opening, and will generally reduce it, but, in the prolapsus of 
the middle portion, the finger or the probe may pass alongside of the 
prolapsus for one or even two inches before reaching the upper 
flexion. 

Etiology. — Eversion of the sphincters, or, at least, a partial pro- 
lapsus of their mucous membrane, occurs extremely often in small 
children. It will generally be found that diarrhoea has preceded for 
some time, and that, as a consequence, the mucous membrane has 
become gorged, pufFj^, and flaccid, and the sphincters enfeebled. 
Persistent constipation may also give rise to prolapsus, the rectum 
seeming to be forced out by the hard and large fecal masses. In- 
vagination of the middle portion, however, occurs oftener from this 
cause than eversion of the lower. In young pups afilicted with the 
so-called distemper, large invaginations of the middle portion of the 
rectum are frequently observed. 

The jyrognosis is favorable in both these conditions, if the children 
are in other respects healthy and weU nourished, and a radical cure 
may be achieved without an operation, but in atrophied children it is 
unfavorable. 

Treatment. — As regards the general treatment it is manifest that 
astringents should be employed in prolapsus from diarrhoea, and that 
mild laxatives are indicated in prolapsus resulting from constipation. 
To the former class, opium, the mucilaginous and vegetable astrin- 
gents, and the nitrate of silver and alum, belong ; to the latter, rheu- 
barb and the neutral salts in small doses. Castor-oil is very difficult 
to administer to small children, who usually refuse to swallow it, or 
reject it by vomiting. 

The reduction of the prolapsus is less a question how to do it than 
when it is to be performed. It is of first importance that it be reduced 
at once, and we should so instruct the parent or niirse, giving at the 
same time the rules for doing it. These comprise the laying of a piece 
of lint, smeared \vith simple cerate, upon the prolapsed bowel ; then, 
seeking the central opening with the finger, thrust it well into the 
bowel, carrying vnih it the prolapsed portion. After the prolapsus 
and finger have thus found their way into the anus, the finger is slowly 
withdrawn with rotatory motion. The piece of Hnt may be readily 
pulled out without danger of inducing the prolapsus anew. In winter, 
or where ice is readily at hand, it is very useful to slide a small round 
piece of ice into the prolapsus before the reduction is undertaken, and 
then to reposit the protruded bowel with the ice. 



DISEASES OF THE DIGESTIVE APPARATUS. 169 

In atrophic children the prolapsus will always recur, no matter how 
often it is reduced, though cauterized or burned. In well-developed 
children this treatment is generally sufficient to cure the aiFection, but, 
when the disposition to prolapsus has existed for a long time, a few 
longitudinal applications of lunar caustic, or fuming nitric acid, may 
become necessary. I have never yet been compelled to use the 
actual cautery in this affection. 

In order to prevent the straining to which some children are ad- 
dicted from mere habit, it is advisable to set the chamber upon a foot- 
stool, so high that the children will not be able to reach the floor 
with their feet, a position which will prevent them from exercising 
any very great abdominal pressure. Experienced nurses know the 
value of holding children, thus afflicted, suspended in the air during 
defecation, and at the same time of compressing and supporting the 
anal orifice as a means of preventing the prolapse of the bowel. 

(14.) MALroEMATioNS OF THE Anus AND Rectum. — We have 
two kinds of malformations of the anus ; (a) a constriction and (b) a 
closure. 

(a.) Constriction of the Anus. — A moderate degree of constriction 
rarely produces marked symptoms so as to require surgical aid. This 
is especially true of children during the first year of life, because their 
faeces in the normal condition are never solid, but always in a semi- 
sohd state and formless. The condition becomes troublesome only 
when constipation supervenes. Evacuation of the bowel then becomes 
difficult or impossible, and tympanitis and even symptoms of in- 
testinal stenosis appear. If the hard alvine matter can be softened 
by frequently-repeated clysters, it will then be discharged, and all the 
symptoms will disappear. The same result may be obtained by laxa- 
tives, but their action in these cases is always attended by severe 
colic-pains. 

Sometimes, however, children are born with such a degree of con- 
striction of the anus, that even the discharge of the meconium is 
delayed and attended with difficulty. It is sometimes such as to 
render it impossible to introduce an ordinary probe into the rectum. 
Here, of course, a small surgical operation is indispensable, and is 
best performed by introducing a grooved sound, dividing the con- 
stricted anal opening upon it with the knife, and then dilating it 
to one-third or one-half of an inch. Pledgets of lint, smeared with 
cerate, must then be introduced into the wound for several weeks, 
in order to prevent a too early closure ; this, Avith the passage of the 
faeces several times a day, prevents the formation of contracting 
cicatrices. 

(b.) Ocdicsion of the Anus {Imperforatio Ani). — In order to 



170 DISEASES OF CHILDREN. 

thoroughly comprehend the pathological history of this condition, it 
is necessary to consult embryology. We are there informed that, at 
a very early date of embryonic life, a connection exists between the 
bladder and rectum, by which the former serves as a cloaca, and that 
the rectum originally terminates in a cul-de-sac, that this cul-de-sac 
extends downward into the lesser pelvis, where it meets a similarly 
blind projection of the external integument, the rudiment of the anus, 
and that not till a mutual fusion of both these sacs has taken place, 
and disappearance of the opposing terminal sac-wall, is a communica- 
tion established between the rectum and anus. 

The following arrests of development may occur, systematically 
dehneated on PI. HI., Figs. 5-9. 

(1.) The rectum is fully developed, but in the natal fold, where the 
anal depression is usually found, nothing of the kind is to be seen, but 
the blind extremity of the rectum reaches to the cutis, which it is 
unable to perforate. This is the simplest and most favorable kind of 
imperforatio or atresia ani. The meconium that accumulates after 
the delivery of the child distends the rectum, bulges out the integu- 
ment beneath, at the spot where the rectum terminates, and a simple 
crucial incision is sufficient for the formation of an anus (Fig. 5). 

(2.) In this condition the anal depression has developed itself 
normally, but is unable to reach the blind end of the rectum, because 
it has either been arrested in its growth (Fig. 6), or it terminates in 
the vagina (Fig. 8), or in the bladder (Fig. 9). In these cases the 
simple inspection of the anus suppHes no explanation, for this part is as 
normally formed as in every healthy child. The non-appearance of the 
meconium during the first twenty-four hours, restlessness of the child, 
a tympanitic and distended abdomen, and refusal to take the breast, 
usually first call the nurse's attention to the state of the bowels. 
Relief is sought in clysters, and the discovery is made that the pipe 
of the syringe either does not go in far enough, or, even when this 
difficulty does not exist, that the clyster is instantly returned. If the 
examination is now made with a probe or silver catheter, it wUl be 
found that the anal depression terminates in a cul-de-sac one or two 
inches deep. 

(3.) There is • in this condition neither an anal depression or 
cul-de-sac, nor has the bhnd extremity of the rectum grown down so 
far as to be traceable, after birth, by an outward bulging of the 
integument (Fig. 7). In these cases, generally, no sign of an anal 
depression is observed in the fissure between the nates, and there is 
no guide by which to judge of the state of the rectum, the blind 
extremity of which terminates in the lesser pelvis at a distance of two 
or three inches from the integument. Sometimes a firm, compact 



DISEASES OF THE DIGESTIVE APPARATUS. lYl 

3ord. runs from the sigmoid flexure to the cutis, which may be re- 
garded as a rudimentary rectum, and renders important services in 
searching for the blind extremity of the bowel. 

(4.) The rectum does not terminate externally, but in the vagina, 
bladder, or in one of the ureters, conjointly with which an anal depres- 
sion may or may not be present (Figs. 8 and 9). In this condition the 
meconium is not absolutely retained, but passes off with the urine in 
one case, and by the vagina in the other. The diagnosis may be made 
with ease by examining the bladder with a silver probe or small cathe- 
ter, and by collecting the urine that contains the meconium ; and still 
more easily when the orifice of the rectum is discovered in the vagina. 
Various are the eflfects of this malformation. In cases where the rec- 
tum communicates with a ureter or with the bladder, the urine always 
becomes alkaline, constantly irritates the mucous membrane of the blad- 
der, and causes cystitis, atrophy, and death. But, when the rectum ter- 
minates in the vagina, it produces a disgusting infirmity, from the con- 
tinuous flow of the fgeces, which are not retained, on account of the 
absence of the sphincters. The child is always soiled about the thighs 
and always emits an odor of fccces, yet it is by no means incapable 
of living. Instances have occurred where the rectum has been es- 
tablished by an operation, and then the connection between the bowel 
and vagina became occluded. 

(5.) Finally, there are cases in which the rectum does not exist at 
all, or only in a rudimentary form. A portion of the large intestine is 
only present, and that terminates in the umbilical region, as a result 
of the embryonical ductus o^nphalo-entericus having remained open, a 
condition that has been denominated mius proiternaiuralis or Ecto- 
pia ani. 

Treatment. — The treatment, naturally, can only consist of an op- 
eration. In the cases spoken of in sec. 1, the operation will be, as 
already indicated, to make a simple crucial incision through the out- 
ward bulging integument, when the meconium will be speedily evac- 
uated. A pledget of lint with cerate is introduced into the wound 
after every evacuation from the bowels, for the first few weeks, in order 
to prevent union of the lips of the wound. 

In the cases mentioned in sec. 2, a cautious attempt should be made 
to find and puncture the rudimentary rectum by the aid of an ordinary 
large trocar, such as is commonly used in paracentesis abdominis. 
The soft, fluctuating tumor will materially aid us in discovering the 
cloaca. An elastic catheter cut ofi^ at the top is then introduced 
through the trocar canula, and through it warm water is injected three 
or four times daily to liquefy the fseces. After several days the cath- 
eter should be replaced by one of larger size, and this practice is 



172 DISEASES OF CHILDREN. 

persevered in till the defecation can take place regularly and without 
any difficulty. Generally the sphincters of the anus exercise theii* 
functions tolerably well, but a disposition to constriction often remains, 
which must be combated by the use of bougies. 

In the form of atresia ani described in sec. 3, a crucial incision to 
the depth of one inch must first be made over the spot where the anus 
normally occurs ; the blind extremity of the rectum may then be sought 
with the finger, arjd, when found, is treated with the trocar in the same 
manner as in the cases described in sec. 2. That these operations fre- 
quently prove fruitless, and even when the rectum is opened often ter- 
minate fatally, might be anticipated from the feebleness of the new- 
born child. 

In cases where the rectum communicates with the bladder, the 
eflfort must likewise be made, as rapidly as possible, to secure a passage 
for the faces by some other channel, because, if not done, a fatal re- 
sult is inevitable. But, in the cases where the rectum terminates in 
the vagina, there is less urgency for an operation, as this condition 
may be tolerated for a very long time ; indeed, instances are known 
where children have grown up with this malformation, M'ithout any 
surgical assistance. As soon as the child has acquired sufficient 
strength, an attempt should, however, be made, even in these cases, 
to establish a proper anus. The communication with the vagina 
will then either become occluded of itself, or it may be very easily 
remedied by a small operation. 

If, in such cases as are described in sees. 2 and 3, it be not possible 
to find the rectum, then, according to the laws of surgery, an artificial 
anus should be made in the left lumbar, or in one of the inguinal re- 
gions. That children may recover from such an operation has often 
been shown, but whether they th^^'e and grow up I am not able to 
say. At least, I have never seen an adult in whom an artificial anus 
had been established in any of these places in the early days of life. 

(15.) Entozo^, Enthelminthes, Helminthiasis (Worm-Dis- 
ease). — Before we enter upon the discussion of the effect of the 
single helminthia, it seems proper to give the subject a simple zoo- 
tomic consideration, for which purpose we take, as a part of our 
ground - work, Bamherger's excellent monograph upon entozoae, 
found in his treatise on the diseases of the abdomen. In the ali- 
mentary canal of children there are found : (1.) Taenia solium ; 
(2.) Taenia mediocanellata ; (3.) Bothriocepbalus latus ; (4.) Asca- 
ris lumbricoides ; (5.) Oxyuris vermicularis ; and, (6.) perhaps, also 
Tricocephalus dispar. Trichinae, which of late have attracted so 
much attention, may occur in older children as well as in adults. 
Small children, so far as I am aware, enjoy a total exemption from 



DISEASES OF THE DIGESTIVE APPARATUS. I73 

the trichina spiralis. This is readily accounted for by the fact that 
they do not eat the meat of the hog, which is known to be a fruit- 
ful source of supply of this entozoon. Since trichinosis of children 
differs in no respect from that of the adult, a descrij)tion of it may, 
therefore, be omitted, as the numerous monographs upon this sub- 
ject have obtained the most extensive circulation and study^ and are 
accessible to every reader. 

(1.) Taenia solium ; (2.) Taenia mediocanellata ; and (3.) Both- 
riocephalus latus. (Cestodise.) 

(1.) Taenia solium (T. cucurbitina, armata, chain-worm), PI. 
IV., Figs. 4-7, is a yellowish white, tape-like, jointed worm, fifteen 
to thirty feet in length, and three to five lines in breadth. Like all 
taenia, it has the male and female sexual organs united in each of its 
developed joints, and propagates itself by eggs, which, however, never 
attain to maturity in the alimentary canal itself. The head, to the 
naked eye, appears as a white point, on which, with a No. 4 mag- 
nifying-glass, blackish pigmented suckers may sometimes be de- 
tected. Between these is the conical proboscis surrounded by a 
double circle of hooks, but the individual hooks are so small, that a 
magnifying power of two hundred is required to see them distinctly. 
The neck is several inches in length, not jointed, resembles a flat- 
tened thread, and gradually merges into the body, which, as already 
stated, is jointed. The first joints have a gi'eater transverse diame- 
ter, which becomes gradually less posteriorly, till toward the end 
they are square or parallelogram in shape, with blunt corners. On 
the latter the genitals are distinctly seen, for a projection is found 
on their borders with the orifices for the vagina and penis, and the 
ovary is seen through their translucent walls. This projection is 
generally situated alternate on the borders of the joints. 

New joints constantly form at the head, while at the tail the old 
joints are constantly cast off. These cast-off segments or joints 
appear in the stools, and are frequently compared to pumpkin-seeds 
in appearance, and thus the definition of tcunia cucurbitina has 
originated. 

[The development of taenia in its different phases has now been 
thoroughly demonstrated. A tape- worm reaches its final growth 
in the intestinal canal, from an embryo — an intermediate stage in 
its course of development — admitted into the canal by means of 
infested meat. Since the introduction of the method of treating 
diarrhoea by the use of finely-scraped raw meat, and the modern 
taste of eating rare steaks, etc., tape-worm has become more common. 
Taenia solium is derived from the embryos contained in pork, known 



174 DISEASES OF CHILDREN. 

as cysticercus cellulosus, and Taenia saginata from embryos found 
in beef. The bothriocephalus is supposed to be derived from an 
embryo found in fish, but not correctly so, as it occurs among peo- 
ples living on the sea-shore, and at the borders of lakes, and in the 
interior of continents as well (Bartholow). The small intestine 
is the abode of taenia, but when very long may reach into the large 
intestine. The head is fixed against the mucous membrane just 
below the pylorus. A single worm is generally met with, but sev- 
eral have been found in one patient. Adults are more liable to 
breed this parasite, but no age is exempt from it, and a case is on 
record where an infant five days old was affected by it.] 

(2.) Tcenia mediocanellata is analogous to the solium, and was 
first described by IxiXchemneister as a separate species. According 
to Leuckart, it is not only longer than T. solium, but is also broader 
and thicker. Especially its unripe members are remarkable for 
their breadth. The comely head is devoid of the circle of hooks and 
rostellum, but provided with four very strong, large suckers, which 
are usually surrounded by a black border. The uterus of the ma- 
ture members is characterized by the large number of side branches 
which do not run parallel to each other, and, instead of displaying 
dentritical ramifications, at the utmost show dichotomical fissures. 
Otherwise, it is very much like Taenia solium. 

Leuckart fed a calf with a mass of T. mediocanellata, four feet 
in extent, and after three weeks found all the muscles, the heart, 
the capsule of the kidneys, the brains, etc., permeated by a countless 
number of cysts resembling the young cysticercus. It may, there- 
fore, be safely considered that cattle are the habitations of this 
entozoa. 

(3.) Bothriocephalus lotus (PI. IV., Figs. 1-3, Taenia lata, the 
broad tape-worm) is very similar to the preceding, but is distin- 
guished from it by the following peculiarities : It is of a darker 
grayish color, the head oblong, with longitudinal depressions, with- 
out snout and without the rows of hooks. The neck is much 
shorter ; all the joints are broader than they are long, and overlap 
each other in the form of slates upon a roof ; and the most charac- 
teristic feature observable on every joint is, that the sexual orifices 
are not on the border, hut in the centre of the joints. 

The eggs are of a brownish color, and glisten through the central 
portion of the translucent walls of every joint like yellowish-brown 
rosettes. The bothriocephalus has, in addition, the peculiarity of not 
readily casting off single mature joints, but always whole rows of 



DISEASES OF THE DIGESTIVE APPARATUS. 175 

joints, and this materially aids us in forming' the diagnosis, since we 
have to rely upon the history of the patient almost entirely. 

These three kinds of worms display a remarkably reciprocal exclu- 
sion. Thus the bothriocephalus occurs only in Russia, Poland, and 
Eastern Prussia, as far as the Weichsel, while taenia solium is seen in 
all the rest of the counti'ies of Europe, except Switzerland, where, 
according to Mayer- Ahrens, they are both observed. 

They are extremely rarely found in children under one year of 
age, in nurslings probably never. Taenia solium, according to JS^uch- 
enmeister's investigations, originates from cysticercus cellulosa of 
the pig, and therefore occurs only in children who partake of hog's 
meat. 

(4.) Ascaris lumhricoicles (Class of Nematodise), round-worm. 

The round-worm, PI. IV., Figs. 8 and 9, is a round, yellowish, or 
reddish worm resembling the earth-worm, of five to ten inches in 
length, and one to three lines in thickness. It is very slightly flat- 
tened, has a mouth and an alimentary canal ; the head is distinguished 
from the body by a constricted point, and is composed of three 
papUlae, which, during the act of sucking, are capable of dilating 
themselves into a broad suction-cup. The male and female can be 
easily distinguished ; the male is smaller than the female, and has a 
curved tail, and occasionally a couple of very fine small white hairs 
are seen close to the end of the tail, indicating the position of the 
penis. According to Kuohenmeister^ if the body of the female be 
pressed, a thin bag (the ovaries) is squeezed out from the vaginal 
opening, which is located in the anterior half of the animal, attended 
by an effusion of a milk-like substance (the eggs). If the male worm 
be squeezed, a milky juice (semen) flows out from near the anus, 
without any rupture or prolapsus taking place. The skin, according 
to GzermaTc^ consists of six layers, and is formed of tape-like trans- 
verse rings which are not endless, but sometimes split dichotomously, 
and usually terminates at the lateral lines of the animal. 

The round-worm inhabits, by preference, the small intestines ; is 
seldom found solitary, but in numbers of from five to ten, and some- 
times as many as two or three hundred. It is much more frequently 
met with in the alimentary canal of children than in that of adults. It 
does not occur in nurslings, but may in small children who are brought 
up by hand on meal-jam or toast-broth. The eggs of this worm are 
undoubtedly introduced into the alimentary canal with the food ; at 
least no other supposition can be assumed, since, according to V. Sie- 
hold^ the female ascarides never bring forth any living young, nor is 
the spawn ever found in the human intestines. They seem to prefei 



176 DISEASES DF CHILDREN. 

amylaceous nutriments, but it does not follow from this fact that all 
children who readily eat bread harbor ascarides. Were it otherwise, 
there would certainly be no child that did not suffer from them. 

(5.) Oxjoiris vermicularis (Ascaris vermicularis, spring-worm, in- 
testinal moth, maggot-worm). Class of Nematodia?, PI. IV. Figs. 10—13. 

The name oxyuris is only apjDlicable to the female, not to the male 
worm. The female is thin, yellowish white, of from two to five lines in 
length, with a straight, awl-like, pointed tail. The male is barely a line 
in length, and has a strongly-curved tail. Both have a bulbous head, 
with two lateral, bladder-like membranes. The female is found in 
vastly greater numbers than the male, and the latter is never found in 
the stools, because it adheres very firmly to the intestinal mucous mem- 
brane, from which, according to Zenker, it may very readily be scraped 
off with the mucus after death. The male worm is still more easily 
collected when the alvine secretions of the large intestines have been 
washed away by diarrhoea. The usual abode of the oxyuris is in the 
rectum. In the large intestines it is found in small numbers only, 
and scarcely, if ever, in the small intestines. It travels from the rec- 
tum, especially when the children lie in warm beds, and wanders to 
the vagina in girls. Kuchenmeister says it is a " superstition " to re- 
gard them as only or chiefly peculiar to childhood, and affirms that he 
has observed them twice in the adult. But every experienced physi- 
cian, who practises in a region where oxyuris is at all common, will be 
able to offset those two adult cases by as many hundreds of cases of 
children, and hence I see no good reason at all for rejecting this 
" superstition," 

(6.) Trichocephalus dispar (Nematodia3). Whip-worm. PI. IV., 
Figs, 14 and 15, 

The trichocephalus is a white, long worm, of from one to two inches 
in length, as thin as a hair at the head, and very gradually grows thicker 
posteriorly, presenting a strong resemblance to a whip-stalk. At the 
tip of the thin extremity an unarmed mouth is found, in which the 
cesophag-us terminates. In the female the posterior part is straight, 
and exhibits a simple, straight vagina, but in the male it is spirally 
twisted ; the end is provided with a small prepuce and a penis. 

This worm is found almost exclusively in the c£ecum and ascending 
colon, and is very seldom seen in the fseces, because, as it seems, it 
very unwillingly leaves the gut. Once, while making a post-rno7'tem 
examination of the body of a girl fifteen years old, who died of chol- 
era on the fourth day, after the most profuse diarrhoea, I found at 
least thirty of these animals in the cfecum, and all the uhvsicians 



DISEASES OF THE DIGESTIVE APPARATUS. 177 

present at the examination expressed their surprise at the animals 
having remained in the bowels for four days with such liquid and 
profuse evacuations. It is very rarely met with in children, and in 
fact has only been described for the sake of completeness. 

Symptoms. — In regard to the symptoms which are occasioned by 
the entozoEe, much has already been written and disputed. Our pred- 
ecessors undoubtedly attributed too great an importance to intestinal 
worms, and believed that many serious diseases were caused by them, 
for no other reason than that, during such disease, these worms passed 
off and then restoration to health followed. The symptoms attributed 
to them became more and more numerous and variable, and finally so 
confused and improbable, that intelligent physicians began to deny the 
existence of worm-symptoms, as many do even at the present day, 
especially the Viennese physicians. Like every thing else that is 
new, this negation found many adherents, and for some time it was 
very fashionable for one not to know any thing about the anthelmin- 
thige. Some symptoms, however, cannot be ignored, and, in order to 
proceed safely, I will only mention those which I myself have observed 
many times. They may be divided into local, general, and reflex 
symptoms; the imaginary symjjtoms which in adult tape-worm pa- 
tients occur so frequently, we may in the Psediatria, fortunately, ignore 
altogether. 

A. Local Symptoms. — Of the local symptoms, those which arise 
from the direct irritation of the entozoae are first of all to be mentioned. 
Pain is a very frequent symptom ; sometimes it is pinching, gnaw- 
ing, boring, etc., and is uniformly intermittent. Various articles of 
food, especially those which are very salty, or aromatic, or sour, 
increase it, and consequently all kinds of fruit aggravate it, while 
milk, oleaginous and fatty nutriments, generally mitigate it. The 
appetite in worm-patients is usually normal, sometimes, however, 
diminished ; it is not easy to decide in children whether it is in- 
creased by worms, because it is well known that at different times 
an abnormal augmentation of the appetite occurs in every child. 
Generally the cause of an augmentation of the appetite is to be sought 
in a more rapid development or more active exercise, and bodily ex- 
ertion, and not in the existence of worms. Vomiting may become 
superadded, either as the effect of the entrance of a worm into the 
stomach, or as a reflex phenomenon, having its source in the irritated 
mucous membrane. Ascaris lumbricoides frequently find their way 
into the stomach, where by their movements they seem to induce retch- 
ing and vomiting, by which, to the great horror of the parents, they 
are sometimes thrown up. The youngest child that I saw throw up 
a round-worm was nine months old, and had merely partaken of a little 



178 DISEASES OF CHILDREN. 

meal-broth, along with the milk of the mother, for only three months. 
The stools are generally irregular; sometimes there is constipation, 
and sometimes diarrhoea is present ; Avith the latter, as a rule, a great 
number of the entozoae are expelled. The large masses of mucus (so- 
called worm-nests), which occasionally pass oflF from tape-worm pa- 
tients, are seldom observed in children, because tape-worm is rare in 
children. 

In girls, oxyuris sometimes travel from the rectum, where they 
occasion incessant itching, into the vagina, redden its mucous mem- 
brane, and give rise to leucorrhoea. The incessant tickling sensation 
they produce is often the stepping-stone to onanism, of which practice 
it is seldom possible to break them, even though the oxyuris have 
long been expelled. In boys they sometimes crawl up under the pre- 
puce, from which balanitis, erections, and similar inclinations to onan- 
ism, may likewise be developed. 

The round-worms extend their wanderings even farther than the 
oxyiuis. They sometimes get into the oesophagus, causing vomiting, 
thence into the mouth and nose, and are even said to have passed 
into the larynx and produced suffocative attacks. In some post-mor- 
tein examinations, abscesses of the liver have also been found, in 
which one or two round-worms were hidden. These have doubtless 
found their way into the gall-ducts through the ductus choledochus, and 
then caused inflammation, hepatic abscesses, and death ; they have 
been also found in the ductus pancreaticus and ajDpendix vermiformis, 
where they produced irritation and suppuration. The extremely rare 
instances in which encysted ascarides were found in the peritoneal sac 
have lately been doubted altogether, because no organ can be de- 
tected on am' part of the body of the worm by which it would be able 
to perforate the intestines. I have not seen such a case, and am there- 
fore unable to decide ; but V. Siehold, one of the most eminent hel- 
minthologists, and known for his conscientious observations, maintains 
that the ascarides are able to insinuate themselves, with their firmer 
cephalic extremity, through the coats of the intestines, and penetrate 
into the abdominal cavity, without it subsequently being possible to 
detect any trace of the perforation of the bowel. The penetration of 
the muscular coat is indeed possible, but how the compact mucous 
membrane and the dense serous coats are made to give way before so 
mild a pressure as the round-worm is capable of exercising, is really dif- 
ficult to imagine. 

B. General and Reflex Phenomena. — Itching of the nose is a 
very common symptom of the presence of worms ; still, it should not 



DISEASES OF THE DIGESTIVE APPARATUS. I79 

be forgotten that almost all children bore and rub their nostrils and 
nose, whether they have worms or not, so that this symptom has no 
great value. I have often seen dilatation of the pupils disappear with 
the expulsion of ascarides, and I consider it, though not a very con- 
stant symptom, one sufficient to merit regard. Convulsions of va- 
rious kinds, especially epilepsy and chorea, have been looked upon as 
being connected with entozo^e. As these views are also entertained 
by the laity, I have in many instances been requested to treat such 
children for worms, but have been unable to detect any entozose, or 
any change in the convulsions, notwithstanding the employment of the 
most energetic remedies. The occurrence of worms in choreic and 
epileptic patients seems, therefore, to be a mere coincidence. 

I doubted, until I finally convinced myself of it, whether worms can 
produce severe hydrocephalic symptoms. Some years ago a child was 
brought to our children's hospital in a dying condition, having been first 
attacked by convulsion a few days before. It presented all the signs 
of a child dying from acute hydrocephalus, and died in a few hours. 

To our great surprise, at the autopsy we found the brain and its 
meninges, the heart and lungs, the liver, spleen, and kidneys, in a per- 
fectly normal state, but in the intestinal canal there were more than a 
hundred round-worms, rolled up in small and large balls, at some points 
completely choking up the calibre of the canal ; the mucous membrane 
itself in the same regions had become reddened.* 

Diagnosis. — By these local and general symptoms a probable di- 
agnosis may, it is true, be arrived at ; a certain one, however, is only 
derived from the appearance of helminthiae in the evacuations, or, in 
the case of tape-worm, the appearance of single pieces. Since the or- 
dinary vermifuge remedies are harmless when given to children free 
from intestinal catarrh or other disease, we are justified in adminis- 
tering them to children presenting the symptoms just described, in 
the hope that the expulsion of worms may confirm the diagnosis. 

Treatment. — (1.) The expulsion of tape-worm may be undertaken 
in children of one year and over, providing they are free from diar- 

* [That the reflex symptoms are sometimes of the most peculiar and variable kind 
is seen from the two following singular cases, which lately occurred to me. In the 
first, a girl three and a half years old, they manifested themselves by a croupous cough, 
differing in no respect from that occurring in genuine croup ; in the second, a boy 
five years old, by severe and protracted toothache of almost all the teeth of the up- 
per jaw, though, on examination, they were all found to be perfectly sound. In the 
former, the cough had a periodic character, i. e., it would come on whenever the oxy- 
uris accumulated in any considerable numbers in the rectum, and would disappear as 
soon as these were expelled ; in the latter, the toothache persisted until a long round 
worm was expelled, since which the boy has been free from it.] 



ISO DISEASES OF CHILDREN. 

rhoea, and otherwise healthy. Very young or teething children toler- 
ate badly even the mildest tape-worm remedies. The simplest and 
surest remedy is cortex radic. punicce granati. The precaution, how- 
ever, should be taken to have it fresh and sufficiently macerated. For 
children of from tAvo to five years, the following formula will be fovmd 
useful: ^. cort. rad. punic. granat. rec. 5 j, macei-a c. aqua fontan. 
libr. j, per horas 24 dein coq. per hor. 12 ad remanent. 3 vj. Two ounces 
to be given at half-hour intervals in the morning, fasting, the bow- 
els haAang been gently moved the preceding day by the use of boiled 
dry prunes. It is advisable to have a double quantity of the granat- 
bark decoction prepared, because occasionally one or the other por- 
tion is thrown up, and in that case should be repeated in half an hour. 
After one or two hours, the whole worm is usually expelled. If this do 
not take place, or if the head of the tape- worm cannot be found in the 
stools, the same procedure may be repeated after a few daj^s, without 
any detriment to the health. Generally no persistent diarrhoea nor 
colics are produced by this remedy, but, when they do occur, they may 
soon be relieved by emulsions. 

Where the fresh bark of granat-root is not obtainable, or if the 
child cannot be induced to take it, other remedies may be resorted 
to. Among these we may mention : Ext. felic, mar. oether 3 ss, the 
blossoms of Brayera anthelminthica, of which an ounce may be given, 
mixed vn.ih. honey into a confection. Drastic purgatives, such as 
gumnii gutti, colocynth., and croton-oil, should under no circumstances 
be given. In sickly children this treatment for tape-worm should 
never be practised. I am conversant with cases in which, notwith- 
standing the presence of the tape-worm, children have gradually 
recovered their health, the worm not seriously influencing develop- 
ment. 

(2.) Ascaris lumbricoides seldom produce any serious disturbance 
or characteristic symptoms, and often pass ofi" in large quantities from 
perfectly healthy children, in which neither any subjective nor objec- 
tive s}Tnptoms preceded. The usual method of expelling them con- 
sists in active purgation with the following substances, viz. •.pulv. semin. 
cinae 3 j, and p>ulv. rad. jalap. | ss, divided into four or five powders, 
which are to be taken at intervals of two hours. It is easier, as a rule, 
to administer these powders mixed with a little water, than when 
made into a confection with honey. Owing to the alkaloids having 
come into such general use of late, it is customary to employ the es- 
sential principles of remedies instead of the gross substance, as they 
possess all the -virtues in much smaller bulk. Hence a few grains of 
santonine are now given in place of a drachm of cinas-seed. But the 
efi"ect of santonine is by no means as brilliant as has been claimed by 



DISEASES OF THE DIGESTIVE APPARATUS. 181 

some ; on the contrary, it is very problematical and much inferior to 
the ordinary cinas-powder. Although the fear of calomel, with which 
some individual therapeutists are affected, is by no means well ground- 
ed, its employment as an anthelmintic has no defence. Children are 
liable to crush the wafer in which the powder is enveloped, in the 
mouth, and then generally get stomacace from it. In all the text- 
books on the diseases of children, ol. ricmi plays a manifold part, and 
some physicians omit no opportunity to make the children happy by 
prescribing a few teaspoonfuls of castor-oil. I have frequently tried 
to administer it, but have succeeded in but few cases, as most children 
refuse to swallow it and spit it out. I have therefore discarded it al- 
together. 

(3.) Against oxyuris vennicidaris internal remedies are of but 
little use ; on the other hand, it is very easy to remove them by clys- 
ters, since they are almost wholly located in the rectum. Various 
vermifuge remedies, such as decoctions of garlic, omo7is, asafoetida, 
Valeriana, tanacetum, or a few drops of turpentine, camphor, salt 
water, and even a weak solution of corrosive sublimate, may be added 
to the clysters. The principal object, however, is always to soften the 
contents of the rectum, and to cause their expulsion once a day. This 
is easily accomplished with simple cold-water. Two cold-water clys- 
ters daily, continued for four weeks, will invariably expel all oxyures. 
If leucorrhoea at the same time be present, cold-water injections will 
be found equally efficacious for that. In the large liquid evacuations 
which follow the first cold-water clysters, such a countless number of 
oxyures is sometimes found, that the liquid faeces are kept in a con- 
stant state of agitation by the swarm of animals. 

(4.) Trichocephalus dispar never produce any symptoms, and are 
scarcely ever seen in the evacuations, but always observed accidental- 
ly at the autopsy ; a description of the method of expelling them is 
therefore impossible and unnecessary. 

The liver is comparatively much larger in the new-born child than 
the yearling. Frerichs, however, is unable to confirm the assertions 
of Portal and MecJcel, according to whom the liver should be one- 
fourth heavier in the new-born child than at eight to ten months. 
That author found that the weight of the liver in comparison to the 
whole body is 



13 



Is 




17 in a seven months' foetus, 


t( 




28 in a new-born child, 


(( 




24 " " " " " 


(( 




OQ (( '( >( " (> 


il 




33 in a child sixteen months old. 



182 DISEASES OF CHILDREN. 

The average weight of the liver of a new-born child is 100 
grammes, but that of a child one and three-quarter years old is 250 
grammes, so that any actual decrease of the structure of this organ is 
altogether out of the question. 

The physical examination of the liver in children is conducted 
very much upon the same principle as in the adult. It is first per- 
cussed in the axillary line (a perpendicular line drawn from the ax- 
illary cavity downward), then in the mammillary line (a perpendicu- 
lar one drawn from the nipple dow^nward), and finally in the sternal 
line (a perpendicular one from the sternum ovitward). By the first 
two lines, the diameter of the right lobe, by the last, that of the left 
lobe, of the liver is ascertained. 

This percussion is rendered very difficult by the restlessness of 
small children, and, in the examination of the position of the liver, al- 
lowance must especially be made for the very important influence 
of the respiratory acts. Older children, from the third year upward, 
may, by friendly coaxing, be induced to allow themselves to be ex- 
amined as quietly as adults. 

Diseases of the liver are extremely rare in young children. As 
we have already described icterus neonatorum in the chapter on the 
diseases originating directly after the delivery, there remain only the 
syphiHtic and fatty livers, and the congenital anomalies of the liver, 
to speak of. The other hepatic diseases, cirrhosis, carcinoma, and 
echinococcus, are very seldom met with in children, and, when they 
do occur, their symptoms differ in no respect from those of the adult. 
Acute hepatic atrophy, so far as I am aware, has never been observed 
in children. 

(1.) Syphilitic Inflajsimatioj^" of the Liver. — Mayer and Ricord 
were the first who pointed out the connection between a peculiar 
morbid alteration of the liver and secondary S3'^philis, but Dittrich 
established it satisfactorily by a number of more accurate investiga- 
tions. In general, however, the disease is very rare. I have dissected 
many children with hereditary s;^73hilis (perhaps fifteen), and al- 
ways carefully examined the hver, but only once found this morbid 
condition. 

Pathological Anatomy. — At the autopsy of children -with con- 
genital syphilis, almost aU of whom, as is well known, perish, a pecu- 
liar kind of inflammation, which attacks the glandular substance of the 
liver, is sometimes found. The exudation of this inflammatory pro- 
cess is partly plastic, and at a later period becomes transformed into 
cicatricial tissue. It, however, rarely reaches this condition in chil- 
dren, for death usually ensues too early. This exudation is composed 
of sero-plastic material, and therefore absorbable, and of a grayish or 



DISEASES OF THE DIGESTIVE APPARATUS. 133 

yellowish mass, whicli exhibits, microscopically, elementary granules, 
oil-globules, and only a few liver-cells. This yellowish-gray material, 
when the process has lasted long enough, is found in masses of the 
size of a hemp-seed, or of a pea, and circumscribed by the plastic sub- 
stance, which subsequently becomes cicatricial. When these morbid 
changes occur at many points of the liver, it thereby acquires an un- 
even, roughened appearance, and the peritoneal covering, if the mor- 
bid alteration takes place on its superficial surface, becomes indurated 
and callous. The free spaces of the liver in children, as a rule, are 
normal ; in adults, cirrhosis, carcinoma, and nutmeg or fatty liver, may 
occur along with the affection under consideration. 

In young children, the form of the liver is rarely changed by this 
disease ; usually nothing is found but a few spots, which, on section, 
prove to be firmer than the normal tissues, have a pale color, and 
are composed of granules, oil-globules, and only a few liver-cells. 

Symptoms and Therapeutics. — The special symptoms belonging 
to liver-disease are slightly marked and difficult to recognize. These 
unfortunate children, who usually are two or three months old, bear 
upon them the signs of hereditary syphilis, such as condylomatous ex- 
crescences around the anus and at the angles of the mouth, ulcers 
about the mouth, ozoena and a syphilitic exanthema. The nutrition is 
very imperfect, and the emaciation extreme. The upper surface of the 
liver may possibly be found irregular or nodular, and its free border in 
some places slightly thickened and more rounded than in health. 

The minor alterations of the liver are, of course, totally indistin- 
guishable, and cannot be diagnosticated. As a complication, we may 
mention fibrous degeneration of the kidney, followed by anasarca. 
The most remarkable feature about this disease of the liver is, that 
icterus never occurs with it, but a grayish earthy hue of the skin su- 
pervenes on approaching dissolution. 

No special treatment can be recommended for this condition. All 
those children who are not fed at the breast of their own mothers, and, 
on account of their liability to inoculate any other woman, cannot get 
a wet-nurse, almost invariably perish, no matter whether their livers 
are aifected at the same time or not. The inunction treatment, where 
the state of the skin allows it, ofiFers the best means thus far known 
for a recovery. This subject will be found more fully treated under 
Therapeutics of SyiildUs. 

(3.) The Fatty Liver [Hepar Adlposum). — ^By fatty liver wc 
understand a greater quantity of fat in the hepatic cells than is nor- 
mally present, and always in such amount that distinct alterations of 



18 J: DISEASES OF CHILDREN. 

color of the parenchyma take place. This change of color is an im- 
portant feature, because, if observed and regarded, we avoid the error 
of supposing that a few liver-cells containing oil, such as may be 
found in every post-mortem examination, must be considered fatty de- 
generation. In the infantile organism, fatty liver is a tolerably fre- 
quent accompaniment of consumptive diseases, especially of pulmonary 
tuberculosis and of protracted intestinal catarrh. 

An attempt has been made to explain its origin in tuberculosis in 
various ways, and most authors are inclined to the view that in this in- 
stance it is produced by the embarrassed respiration, in consequence of 
which the oxidation of the hydro-carbons and fat cannot properly 
progress. But Frerichs very correctly observes that very many more 
decided distm-bances of the respiration, pulmonary emphysema, for in- 
stance, do not induce fatty livers, and that, on the other hand, in other 
tuberculous diseases, such as tuberculosis of the bones, in which the 
lungs may be totally unimpaired, the fatty liver may also be found 
present. 

He believes, therefore, that here the cause must be sought in the 
altered state of the blood that supervenes dm-ing the process of ema- 
ciation, and which consists in its becoming overloaded with fat, which 
in the progressive emaciation is absorbed. Hence the fatty liver is 
more marked in pulmonary tuberculosis than in other consumptive 
diseases, because in unimpaired lungs a greater consumption of oxygen 
takes place, and consequently a more rapid transposition of the excess 
of fat in the blood is effected. 

Pathological Anatomy. — A well-marked fatty liver has a larger 
surface than the normal organ, is flattened, and its margins are thick- 
ened and rounded. Its upper surface is smooth, glistening, whitened, 
and has a doughy feel ; the pressure of the finger leaves an impress. 
In color it is yellowish red or pale yellow, and a dry, slightly-warmed 
blade of a knife becomes coated \nth. fat when drawn through its sub- 
stance. The quantity of fat, as ascertained by analysis, is very con- 
siderable. In one case Frerichs found 78 per cent, in the dried sub- 
stance of the hver ; in the fresh state, the same liver contained 43.84 
fat, 43.84 water, and 12.32 tissues, cells, vessels, etc. Simultaneously, 
the normal quantity of the water of the fatty liver becomes diminished, 
and may fall from 76 per cent, down to 43 per cent. The fat consists 
of olein, margarin, and traces of cholesterin. 

In less-marked cases these pathological characteristics are also less 
distinct. As the hepatic lobules always become affected in such a 
manner that the cells Ij'ing on the periphery of each lobule first un- 
lergo fatty degeneration, while the centre of the lobule, about the he- 
patic veins still remains free and of a normal color, a reticulated ap 



DISEASES OF THE DIGESTIVE APPARATUS. 185 

pearance of the incised parenchymatous structure is produced, called 
the nutmeg-liver. 

The brownish-red and pale-yellow substances alternate in such a 
manner, that the first forms small islands, which are surrounded by the 
latter like a bright-yellow zone. The form of the brown islands de- 
pends upon the direction in which the lobules have been cut through. 
Where the central veins have been cut through transversely, they 
are round ; where the incision falls parallel with the central veins, 
they will represent oblong or leaf-like figures. 

The deposition of fat does not always take place in all parts 
of the liver alike, hence the islands differ in size, especially those near 
the surface of the liver, where they may be scarcely changed from the 
normal appearance. 

The microscopic appearance is very characteristic. The morbid 
change is limited to the liver-cells only, and no free fat is ever found 
in the intercellular spaces of the parenchyma. The hepatic cells, 
which, in the normal condition, are but slightly granular, exhibit at first 
fine, minute oil-drops within their walls, which, increasing in number, at 
length become confluent, and obscure the primitive cell-granules. The 
normal constituents of the cell thus obscured may be again rendered 
visible by removing the newly-deposited fat by the addition of oil of 
turpentine. The form of these fat-loaded cells is generally roundish, 
their angles having disappeared. 

As regards the remaining functions of the liver, it is remarkable how 
little they are disturbed. The sugar-generating function of the liver, 
a modem discovery, but now well understood and appreciated, does 
not become deranged, nor does the bile it secretes deviate in quality 
or quantity from the composition of the normal fluid. 

It is very difficult to define the boundaries between the physio- 
logical and pathological fatty liver, as it is met with in almost all 
nurslings, from whatever disease they may have died. All young 
animals who are still nursing usually furnish the same condition. 

The disappearance of the fatty liver, as the age of the animal in- 
creases, is proof positive that the fat-infiltrated cells do not become 
destroyed, but that the liver becomes normal by a disappearance of 
the fat, and that therefore the fatty liver, under certain circumstances, 
may also be curable. The most frequent pathological conditions with 
which fatty liver associates are : tuberciilosis, next rachitis, then here- 
ditary syphilis ; and, lastly, those diseases which lead to atrophy, 
such as enteritis folliculosa, diphtheritis, acute exanthemata, and ty- 
phus fever. 

Symptoms and Treatment. — It may have been concluded, from 
what has been already said, that the symptoms of this condition are 



186 DISEASES OF CHILDREN. 

very uncertain and unreliable. An enlargement of tlie dulness in the 
hepatic region is the first cardinal point in the diagnosis, although ab- 
sence of this sign has no conclusive significance whatever ; for in 
many instances a decidedly fatty liver is found without the least in- 
crease in volume. The fatty liver, however, does frequently become 
enlarged, flattened, and pushed forward against the abdominal walls, 
where it may be discovered by palpation and percussion. Such 
cases also present the condition called abdominal plethora, which con- 
sists in abdominal gaseous development, giving rise to flatulence 
and disposition to diarrhoea. The diagnosis becomes most probable 
when the above-mentioned diseases, tuberculosis, etc., have existed 
or still exist. 

The fatty liver of children will hardly ever become the object 
of direct treatment. When it is possible to remove the condition 
which caused it, it will disappear spontaneously ; if not, there is 
no remedy that will exercise a direct influence upon the fat of the 
liver. 

(3.) Congenital Anomalies. — The malformations of the liver 
are either very insignificant, simply afifecting its form, or they may 
affect its organization so seriously as to compromise the hfe of the in- 
fant. As regards the deviations from the normal form, we have a 
quadrangular, triangular, flat, or round form ; the division of the lobes 
may either be absent altogether or multiplied. As regards the great 
anomalies, we may mention, first of all, the total absence of the liver 
in monsters, especially acephalije. In diplogenetic monsters a double 
organ is also present. Similar malformations are observed in the gall- 
bladder and ductus choledochus. In congenital fissure of the diaphragm, 
which, on the whole, very rarely occurs on the right side, the liver 
may mount up into the right pleural cavity, and in congenital rupture 
of the umbilical cord [vide p. 66) it may lie exposed through the ab- 
dominal fissure. 

In congenital transposition of the viscera the liver lies in the left 
hypochondrium, and with this a total or partial transposition of the 
rest of the abdominal and thoracic viscera is always combined. The 
spleen, as a rule, is cut up into small spleens, which lie in the right 
hyponchondrium ; the cardiac orifice of the stomach on the right, the 
pyloric on the left side, and the heart in the right thorax. 

Hyrtl has seen this transposition of the liver and of the rest of 
the viscera only four times. I have never yet met with it. The diag- 
nosis cannot by any means be difficult, if a due amount of judgment 
and care be exercised in the examination. 



DISEASES OF THE DIGESTIVE APPARATUS. 



Y.— SPLEEN. 



187 



Idiopathic, primary affections of the spleen probably never occur 
in children, but in some acute diseases a secondary enlargement of this 
organ originates, such as has been more minutely described in typhus 
abdominalis. It is not as easy to detect an enlargement of the spleen 
in the child as in the adult, because children, up to the third year, 
are generally much averse to a protracted examination of the splenic 
region. It is best to examine them in the dorsal or right lateral 
decubitus. A normal spleen can never be discovered by palpation ; 
and even the decidedly hypertrophied spleens are often so movable or 
so soft, especially in typhus fever, that they frequently escape detec- 
tion. The hard, indurated splenic tumor, found in advanced rachi- 
tis and in chronic intermittent fever, may be discovered by palpation, 
and, in subjects much emaciated, may even be seen pushing out the 
thin abdominal covering. It moves dov^^nward with every inspira- 
tion, and upward with every expiration. 

In moderate hypertrophy the spleen retains its oblique direction 
downward and forward; but, in chronic and more marked indura- 
tions, it will assume a more vertical position in line with the body, 
as the ligament pericolicum, which in the normal condition gives it 
an oblique direction, gradually becomes elongated. The form of the 
spleen, wherever it can be felt, is very characteristic. It is an oblong 
oval, with blunt borders, and an indentation on the internal aspect 
at about the middle of the tumor. 

In the examination of the spleen by percussion, very gentle blows 
should be given, particularly when the intestines are tympanitically 
distended, because, by heavy blows, the tympanitic resonance of 
stomach and intestines is developed, and the splenic dulness is lost. 
This examination should be practised with the patients always in the 
same position, because variations of the posture alone produce de- 
cided changes in the dulness. In general, all those dull sounds of the 
splenic region, which in children under one year extend under the 
pleximeter, beyond the normal boundary, are to be considered patho- 
logical. In marked ascites, and in serous eflFusions into the left pleu- 
ral sac, the dulness of the spleen cannot be detected by percussion at 
all ; it also disappears in intense tympanitis, so that, even when the 
hypertrophy of the spleen is considerable, a perfectly sonorous tym- 
panitic percussion-sound may be heard over the corresponding space. 

Besides the occurrence of the splenic tumor in typhus fever, it 
is invariably present in intermittent fever, and a description of the 
latter may therefore very properly follow here. 



188 DISEASES OF CHILDREN. 

(1.) Peritonitis Acuta and Chronica. — Pathologically, all the 
forms of peritonitis are met with in the new-born child. The idio- 
pathic is the rarest form, and is almost exclusively seen in the foetus ; 
the secondary is the most frequent, and the metastatic occurs in 
lying-in houses in which puerperal fever prevails. The latter forms 
cannot always be positively distinguished. The process takes its 
starting-point, in both, from the umbilical vessels, which are filled 
with ichor ; but whether the inflammation is simply extended to the 
contiguous peritonaeum, or whether this membrane, like other serous 
coats, becomes attacked by the pysemic process, is often impossible 
to decide. This kind of peritonitis, depending upon an ichorous 
navel, is only liable to occur so long as the latter exists, six, or, at 
the utmost, eight weeks after birth. After that time the traumatic 
form is only seen, such as that occurring after burns, and perfora- 
tion of the stomach or bowels, or that resulting from an incarcerated 
hernia, or from intussusception. As a disease of the female sexual 
organs it scarcely ever occurs. The tuberculous form is also rare. 

Symptoms. — In peritonitis of the new-born child, pressure upon 
the abdomen is always painful, so much so, that the sufferers will 
utter loud but abrupt cries, even at the slightest touch. The child 
is not capable of crying continuously, because the employment of 
the abdominal muscles for tliis purpose augments the pain. It is 
quietest when completely uncovered, and the abdomen is entirely 
exposed, the legs are extended, and the thighs not drawn up against 
the belly, as is usually the case in colic, because the pains seem to 
become aggravated even by the contact of their own thighs. Older 
children suffei'ing from the peritonitis always maintain the dorsal 
decubitus, and cannot be induced to lie upon the one or the other 
side. A paretic state of the abdominal muscles is present in all 
cases, and a more marked tympanitis in consequence. In the ncAv- 
born child fluctuation can never be felt, because (1) the exudation 
is a plastic merabranosis, and (2) the tympanitic bowels press against 
the abdominal walls in such a manner that the fluid exudation when 
present is below and behind the bowels. 

Vomiting is much less regularly observed in peritonitis of children 
than in that of adults, and diarrhea is oftener present than constipa- 
tion. The appetite is completely lost, but the thirst is great. If the 
peritonitis has reached the serous coat of the bladder, retention of 
urine will supervene, or a few drops only are discharged at a time, 
attended by severe pain. The febrile signs are always distinctly 
pronounced ; the skin is hot and dry, the pulse frequent and small, 
and the breathing rapid and superficial. The respiration is distin- 
guished from that of health by the circumstance that the diaphragm 
does not act at all, or but very little, while the pectoral muscles seek 



DISEASES OF THE DIGESTIVE APPARATUS. 



189 



to produce the utmost possible dilatation of the thorax. But, since 
the proper inflation of the lungs cannot by any means be accom- 
plished by this kind of respiratory act, the children are compelled to 
execute one deep diaphragmatic inspiration for every ten to fifteen of 
those superficial ones, and this, being attended by pain, is accompanied 
by distortion of the face, and frequently by a pitiful cry. The color 
of the face is oftener pale than flushed ; convulsions occur here less 
frequently than in pneumonia. 

Peritonitis of the nursling, as a rule, terminates fatally after 
from one to three days. Tuberculous inflammation of the peritonaeum 
of older children runs a longer course, and may even last for many 
months. But the lethal termination is lalso in this form almost 
unavoidable. 

Pathological Anatomy. — The peritonasum exhibits at dififerent 
places, especially on the contiguous surfaces of two intestinal coils, 
capillary injection and plastic exudation, by which complicated ad 
hesions are produced. In peritonitis of the new-born child, which 
is due, almost invariably, to a phlebitis umbilicalis, the principal mor- 
bid alterations are found about the umbiHcal ring and on the concave 
surface of the liver, which, by plastic exudation, becomes agglutinated 
to the neighboring organs, the stomach, and large and small intestines. 
In the small pelvis some ounces of a purulent, sanious, or bloody 
fluid, are usually found. In the two cases of fetal peritonitis recorded 
by Millard, numerous tense bands and old adhesions were found 
present in the cadavers of the still-born infants. Lobular pneumonia 
is often present as a complication. 

The treatment of peritonitis, as may be gathered from what has 
been hitherto said, is a most unsatisfactory one. That resulting from 
phlebitis umbilicalis seems almost invariably to be fatal. The treat- 
ment, therefore, which secures rest, cleanliness of the navel, and the 
best possible sustaining measures, seems the only one indicated. In 
tuberculous peritonitis, hectic fever, as a rule, is present, and, as its 
subjugation is altogether out of the question, we have to be content 
with trying to remove the febrile symptoms by the aid of small doses 
of quinine and morphine. For the peritonitic pains I use warm moist 
compresses, which are covered by a piece of gutta-percha cloth, and 
this by a dry cloth. They are much cleaner and more convenient to 
apply than cataplasms, which, especially at night, become cold and 
hard, and possess at no time any superiority to the application recom- 
mended. Traiimatic peritonitis does, indeed, tolerate an antiphlogis- 
tic treatment to the extent of from three to twelve leeches, and, in 
case no diarrhoea be present, the addition of several doses of calomel, 
gr, ss. to j, during the day, till a green diarrhoea takes place. The 



^QQ DISEASES OF CHILDREN. 

warm-water compresses above described should always form part of 
this antiphlogistic treatment, for they afford the greatest^ relief. 
If the pains are very persistent, opium is also indicated, as it is m 
most painful diseases. 

(2.) Ascites. Hydkopsical Effusion ixto the Peeitoneal 
Sac— Ascites is never a primary affection, but always a mere symp- 
tom of some other constitutional or circulatory disturbance. In young 
children it is inconsiderable as to quantity, often only a few table- 
spoonfuls of serum being found at the autopsy. Thus, children who 
die from hereditary syphilis, tuberculosis, marasmus, the effects of 
enteritis, from congenital malformation of the heart, or scleroma, have 
small serous effusions in the abdomen. Considerable, easily-demon- 
strable effusions occur only in children who are over one year of age, 
and generally as a result of scarlatina, or of intermittent fever, and 
occasionally, but less frequently, of abdominal typhus. 

Pathological Anatomy.— In old children the quantity of the as- 
citic fluid may reach several pounds. The color of the serum is a wine 
yellow ; sometimes a little coloring matter of the blood is also mixed 
with it. The reddish color thus produced may, however, also be due 
to one or another of the cutaneous veins having been cut at the 
opening of the abdomen, and their contents escaping into the peri- 
toneal cavity. The chemical investigation gives a large percentage of 
albumen, and the salts as they are found in the serum of the blood. 
The peritonjBum is either perfectly normal, or at some places displays 
white opacities, which are prmcipally observed in protracted cases of 
ascites. Occasionally one of the intestinal coils or the liver is coated 
with a thin layer of exudation, so that we have to deal here with a 
transition into true peritonitis. In no autopsy should the mere 
finding of ascites content us, but its cause, one of the above-men- 
tioned affections, should be sought for, in which the heart and kid- 
neys, in particular, are to be subjected to the most scrutinizing inves- 
tigation. 

Symptoms.— The existence of ascites can only be satisfactorily 
proven by distinct fluctuation. Small effusions can never be detected 
in the dorsal decubitus ; occasionally they may be discovered, by laying 
the children on the right side, and slightly elevating the pelvis, where- 
by all the serum then gathers into the right hypochondrium. The 
smallest quantities, however, may be detected by laying the child upon 
its belly, and then causing it to be raised up, so that the navel will 
form the most depending part of the whole abdomen. As in this po- 
sition all the serum must gather round about the navel, it is then 
easily detected by percussion from below upward. Fluctuation is 
ascertained in this manner. The palmar surfaces of the fingers of one 



DISEASES OF THE DIGESTIVE APPARATUS. 191 

hand are made to press against the abdominal parietes, wliile with 
the tips of the fingers of the other the abdomen is quickly and lightly 
struck at a point opposite to the pressing hand, or at least at a distance 
of a few inches from it. The undulation thus produced, in case fluid 
be present, between the pressing and the striking hands, communicates 
a peculiar thrill to the former. Besides being produced by the free 
fluid of ascites, fluctuation also originates from the presence of diar- 
rhceal contents of the intestines, from a bladder filled and mounting 
over the symphysis, and even from oedema of the abdominal walls, 
which, especially in nephritis after scarlet fever, is commonly very in- 
tense. The latter, however, is readily distinguished from true ascites, 
by the pitting from the pressure of the finger, and by the superficial 
character of the flaccidity. The distended bladder is easily emptied, 
and the intestinal catarrh readily relieved by a mucilaginous diet and 
small doses of opium, whereupon the true state of affairs will become 
manifest. 

In mild grades of ascites, nothing can be discovered externally, 
and the circumference of the abdomen is not materially increased ; 
but in , the higher grades attention is attracted to the size of the 
belly, even at the first sight. The integument is glistening and tense ; 
there is flatness on percussion of the lower part of the abdomen, the 
dulness extending over a large surface ; the umbilical ring is distended, 
and the navel prominent. The pressure of the serum excites frequent 
inclinations to micturate, but only small quantities of urine are evacu- 
ated at a time. 

The general phenomena, loss of appetite, fever, respiratory dis- 
turbances, etc., correspond with the conditions causing the ascites. 
The patients, as a rule, perspire but little, and pass very small quan- 
tities of urine. It is mostly dark-colored, and, in nephritis, contains 
albumen and fibrous casts. The stools are often diarrhoeal. 

The prognosis does not depend upon the amount of the ascites, 
but upon its etiology. It may be regarded as unfavorable in almost 
all kinds of ascites, except in that originating after scarlatina, typhus 
fever, and hypertrophy of the spleen from febris intermittens. 

Treatment. — This, of course, varies according to the cause. The 
conditions which give rise to ascites are of such a hopeless natm'e, that 
any special treatment, except a stimulating regime, will hardly be 
indicated. A'VTien caused by nephritis, after scarlatina, rooh * juni- 
peri, which children usually take very readily unmixed and un- 
diluted, is an excellent diuretic remedy ; I direct on(;-half or a 
whole teaspoonful to be taken daily. It is also applicable in ascites 

* [This is the succus spissatus juniperi of the European pharmacopoeias, and i> 
eomewhat stronger than a fluid extract.] 



192 DISEASES OF CHILDREN. 

after intermittent or tj'plius fever, but then a tonic treatment, con- 
sisting of a meat diet, beer, wine, and small doses of iron, is to be 
recommended in addition. The ascites whicli comes on after scarla- 
tina subsides more rapidly than any other. 

(3.) Morbid Alterations of the Mesenteric Glaxds. — In all 
cases of enteritis folliculosa, the mesenteric glands become hypertro- 
phied and indurated, and their impermeability most probably affects 
the atrophy that so frequently follows it, a detailed description of 
which has already been given in connection with that disease (p. 156). 
In addition, cheesy tubercles of the glands occur in older children ; and, 
in those who perished by typhus fever, hypertrophy, or small ab- 
scesses of single glands, are sometimes met with. 

The diseases of the mesenteric glands do not seem to give rise to 
any sjnmptoms, but the nutrition, if a large number of the glands is 
involved in the hypertrophy, suffers very quickly. The glands, on the 
whole, are so small, and the bowels are always too tympanitic, to 
allow them to be felt. 



CHAPTER III. 

DISEASES OF THE ORGANS OF CIRCULATION. 

A.— HEART AND VASCULAR TRUNKS. 

(1.) Congenital Anomalies. — For the purpose of correctl}' un- 
derstanding the congenital anomalies of the heart, this much of the 
embryology has to be premised: that the heart and roots of the 
vessels at the commencement of development are not hollow, but 
consist of a loose conglomerate mass of cells, without any chasm or 
channel, and without any cavities. At this period the heart still 
possesses the form of a straight cylinder, which above and below 
terminates in two prolongations ; the two lower prolongations, the 
venae omphalo-mesenterica, are the roots of the vessels which subse- 
quently ramify in the germinal vesicle and conduct the blood from it 
to the heart; the two upper prolongations are the two future first 
aortic arches, which, in the embryo, carry the blood from the heart. 
The external upper surface, according to J3lschoff, very gradually 
becomes firmer by the cells being deposited closer to each other, and 
thus the walls are formed, and a cavity is developed within, in which 
the fluid and cells, forming the first trace of the blood, accumulate. 
The cardiac cylinder then assumes an S-like shape, and begins to 



DISEASES OF THE ORGANS OF CIRCULATION. I93 

contract and dilate in a slow rhythm, by which its fluid contents are 
propelled anteriorly and upwardly into the aortic arches, while that 
from the venous trunks, on the other hand, is sucked in from below 
and behind. 

By-and-by this cardiac canal, by various curvings, dilations, and 
constrictions of single parts, becomes the heart proper, consisting of 
the aortic dilatation, one ventricle and one auricle. The septa do not 
become developed till a later period, by which the right and left 
ventricle and auricle are formed. Imperfect development or faulty 
insertions of these partition-walls are the most frequent causes of mal- 
formation of the heart. 

Nevertheless, cases of malformation are also observed as the result 
of an embryonal inflammatory process of the muscle of the heart, and 
its consequent atrophy and cicatrizations. 

The best compilations on the congenital anomalies of the heart 
are to be found in the text-books of MoJcltanshy and Jiamherger^ 
which have furnished the basis for the following summary : 

(1.) Absence of the heart (acardia) occurs only in monstrosities, 
where the upper half of the trunk is at tlie same time wanting, and 
the nervous system consequently exists only in a rudimentary form. 
The converse of this is the duplex heart in double malformations 
(diplogenesis) ; this occurs especially in doubling of the upper half 
of the body, where two completely-separated hearts either occupy 
each a separate pericardium or a common one. 

(2.) Abnormal situation of the heart. — Here we may have the 
foetal heart occupying a central position in the thorax, or transposed^ 
so that the cardiac impulse is felt at the right of the sternum. In 
this latter case we have generally an accompanying displacement of 
other organs, particularly the liver and stomach. 

Again, the sternum may be absent and the integument wanting, 
and when this condition occurs we have the heart entirely exposed, or 
merely covered by the pericardium. 

If a greater portion of the thoracic and abdominal walls is want- 
ing, we have the condition called eventration, in which the abdominal 
organs lie without the body. 

In very rare instances a defect or splitting of the diaphragm occurs, 
and the heart then penetrates through this opening into the abdominal 
cavity. 

(3.) Abnormal shape and size. — Variations of the shape of the 
heart are often devoid of importance. It may be broad, cylindrical, 
or fissured at the apex. A pointed and a round heart may perform 
its functions naturally, whereas, on the contrary, abnormal bigness or 
sraallness of the whole heart, or some of its parts, is complicated with 



194 DISEASES OF CHILDREN. 

functional disturbances. The right ventricle is most frequently found 
enlarged in consequence of the foetal circulatory passages having re- 
mained open. 

(4.) Abnormal formation of individual parts of the heart. — Here 
we meet Avith abnormities {a) of the septa., (b) of the roots of the 
vessels, and (c) of the ostia (orifices) and valves. 

(a.) If the formation of the septa has failed to take place, there 
will be but one ventricle and o?ie auricle. Generally, however, the 
septa are indicated by projecting bands, or are fully developed in 
one or the other chambers, so that there may be two completely sep- 
arated auricles and only one ventricle, or vice versa. As the foramen 
ovale, even in the physiological state, at first furnished a small com- 
munication between both auricles, so do we also here find the most 
frequent defects. It also happens, sometimes, that the left auricle 
communicates with the right ventricle, or, vice versa, through an 
oblique communicating passage. Most of the cases are then also 
complicated with extensive defects of the septa and faulty origin of 
the roots of the large vessels, which may also be produced by the 
insertions of the septa having left the median line. It thereby be- 
comes possible for the inferior vena cava to terminate in the left 
instead of the right auricle, or for the aorta to originate from the right 
side of the heart. 

(b.) As has been already stated, abnormities of the roots of 
the vessels depend, in a great measure, upon an imperfect develop- 
ment or faulty insertion of the septa. The most frequent devia- 
tions are : 

(1.) The pulmonary artery is either entirely absent, or is very 
much constricted at its origin, and only becomes dilated beyond the 
duct, arter. Botalli, which conducts the blood to it from the aorta. 
When there is only one ventricle, the aorta supplies the place of the 
pulmonary artery. 

(2.) What has been said of the pulmonary artery may also happen 
with the aorta — it may be misshaped or completely closed ; it then 
receives its blood from the pervious remaining ductus Botalli. 

(3.) The fetal type of the distribution of the blood is wholly 
retained, the aorta supplying the upper half of the body with blood, 
and the pulmonary artery, through the Botallian passage, the lower 
half of the body. 

(4.) A transposition of the large vessels has taken place, the aorta 
springing from the right, the pvilmonary artery from the left ventricle. 

(5.) Both vessels originate from one ventricle. 

(6.) The aorta has two equal or unequal roots, one of which 
springs from the left, the other from the right ventncle. 



DISEASES OF THE ORGANS OF CIRCULATION. 195 

(7.) The bulb of the aorta is immensely enlarged and represents a 
third ventricle. 

(8.) The ductus Botalli often remains permeable, or is absent 
altogether, or may become developed into a permanent vascular 
trunk. 

The partial occlusion of the aorta at the other side of the opening 
of the Botallian passage deserves a more detailed description, an 
anomaly which has been closely investigated, especially by JRokitansky. 
A great constriction of the aorta occurs at this place, which may be 
but a few lines in length, and then terminates in an aorta descendens 
of a perfectly normal calibre. This anomaly is produced by the arteria 
pulmonalis in the foetus forming an arch, is continued in the descend- 
ing aorta, while the blood of the aorta is only transmitted into the 
arteries of the head and arms, the innominata, carotids, and subclavia 
sinistra. The blood of the pulmonary artery flows through the wide 
duct. Botalli into the aorta. A narrow vascular piece runs to the arch 
of the pulmonary artery, which may be regarded as a continuation of 
the aorta, and is described under the name of isthmus aortae. After 
birth, the course of the blood is deviated from the duct. Botalli by 
the dilatation of the lungs ; that passage soon becomes impermeable 
and obsolete, and, at the same time, the originally narrow vascular 
piece, the isthmus aortse, becomes dilated to the diameter of the nor- 
mal aorta. Now, if this dilatation of the aorta does not take place 
after birth, and the Botallian canal nevertheless becomes obliterated, 
a permanent constriction of the isthmus aort^ will be the result. 

A collateral circulation then forms for the blood from the left side 
of the heart, the road for which to the lower half of the body has thus 
become obstructed, by which that section of the aorta below the con- 
striction is nevertheless filled with blood. For this purpose, the 
branches of the subclavian artery become dilated, and assume a ser- 
pentine course. The most important branches which enter into the 
formation of this new connection are : the internal mammary, the rami 
intercostales, which conduct the blood into the rami intercostales pos- 
teriores, anastomosing with them, and which originate from, or, more 
correctly speaking in this case, terminate in the descending aorta. 
Further, the anastomoses between the internal mammary, superior 
epigastric, and the lumbar arteries ; next the arteria intercostales 
suprema with the intercostal branches of the mammary ; and, lastly, 
the arter. dorsalis scapulas with the dorsal branches of the intercostal 
arteries. 

In this manner, the descending aorta becomes completely filled ; 
still it never acquires the normal calibre, whereas the arch of the aorta 
up to the place of constriction is seen to have become completely 



196 DISEASES OF CHILDREN. 

dilated. These individuals are perfectly capable of living many 
years. 

(9.) The venous terminations in the auricles may be transposed in 
the same manner as in the case of the arteries with the ventricles, or 
the vena cava and the pulmonary veins terminate in one auricle only, 
etc. 

(c.) Congenital abnormities of the valves, and ostia in general, are 
comparatively rare, and can more readily be attributed to fetal inflam- 
matory processes, fetal myocarditis, than to an actual arrest of devel- 
opment. The most frequent occurrences are : 

(1.) Stenosis of the conus of the pulmonary artery, or of the aorta, 
a condition in which the muscular structure forming the conus has 
become converted into a white callous mass. This stenosis occurs 
more frequently at the pulmonary artery than at the aorta, and, ac- 
cording to Baniberger^ is one of the most frequent causes of congenital 
cyanosis. The foramen is invariably found open, or the septum of the 
ventricle has not even become completely developed. 

(2.) The valves may be cartilaginous, h3rpertroplued, or the auric- 
ulo-ventricular valve thickened, and numerous columnae papillaries, 
and falsely-inserted chordee tendinaj, occin- ; or, on the contrary, the 
valves are transparent, very much attenuated and perforated. In 
rudimentary construction of the large arteries or false insertion of 
the septa, the tricuspid or semilunar valves may also be completely 
absent. 

(3.) The vahe of the foramen ovale may be absent altogether, or 
become prematurely closed ; various malformations have already been 
observed on the Eustachian valve too. 

Symptoms.- — Numerous descriptions of the congenital malforma- 
tions of the circulatory apparatus are to be found in the dissertations 
and larger monographs, but the symptoms accompanying them are sel- 
dom pictured sufficiently in detail, and, even where this is the case, they 
will be found, as a rule, not to harmonize in one and the same ana- 
tomical condition. According to Samherger, all the malformations in 
reference to their symptoms may be comprised in three groups : 

(1.) To the first group all the malformations belong which pro- 
duce an absolute incapacity for living, such as monstrosities, ectopia of 
the heart, with absence of the integument, complete univentricular 
heart, and transposition of the large vessels. 

(2.) In the second group may be included all those malformations 
with which children may indeed live, and laboriously or even nor- 
mally continue to develop throughout the first few years, still with every 
additional year they experience an aggravation of their disturbances 
of the circulation, so that death ensues in the course of the first, at 



DISEASES OF THE ORGANS OF CIRCULATION. I97 

tlie latest in that of the second dentition. To this class belong: con- 
genital constriction of the conus of the pulmonary artery, and that of 
the aorta, extensive communications of the ventricles, or of the auri- 
cles, or of a ventricle with its opposite auricle, the origin of the aorta 
from both ventricles, and the remaining previous state of the duct. 
Botalli. 

(3.) There is a number of minor anomalies, by which the circula- 
tion is in no way impeded, and consequently no hinderance whatever 
is offered to the development of the child. To this group belong par- 
ticularly the external alterations in the form of the heart, the splitting 
of the cardiac apex, and the conical, cylindrical, broad, and circular 
form. The transposition of the heart to the right side, generally com- 
plicated with transposition of the liver and stomach, is devoid of 
any influence upon the continuation of life. The remaining open of 
the foramen ovale is likewise entirely unimportant, as has already been 
proven by numerous post-mortem examinations, nor is there the least 
plausibility for regarding it as the cause of cyanosis, to which, how- 
ever, we wQl recur once more, further on. 

The time of the appearance of symptoms is extremely variable. 
It is certainly true that the disturbances of the circulation produced 
by congenital defects of the heart may, at first, be insignificant, and 
may very gradually increase from month to month, but the state- 
ments of some authors seem very improbable, who maintain that con- 
genital defects of the heart do not give rise to any symptoms till 
after many years, even not till after puberty. Those authors un- 
doubtedly have fallen into some error, and certain acute diseases of 
the heart have been overlooked. Many children, on the whole, have 
displayed the most distinct signs of marked disturbances of the cir- 
culation immediately after birth. They come asphyxiated into the 
world, and soon after perish by atelectasis of the lungs. They cry but 
lowly and discontinuously, are always cool, somewhat cyanotic, sleep 
a great deal, and suffer from convulsive attacks of coughing, by which 
the cyanosis rapidly increases, and the protruded tongue especially 
assumes a dark, bluish-red color. 

Cyanosis is always the most constant and reliable symptom, but 
concerning its origin joartially incorrect views still exist. Formerly, 
it was assumed that cyanosis in congenital malformations of the heart 
was produced by the mixing of arterial and venous blood, as thus, 
when dark-red blood, in the normal condition, found its way into 
the arterial system of vessels. That this view is incorrect is seen 
from the forms of cyanosis, in which the anatomical conditions of the 
heart are perfectly normal, for example, in cholera or in poisoning 
with carbonic-oxide gas. In these cases, as is well known, the cyano- 
14 



198 DISEASES OF CHILDREN. 

sis is of an intense degree, and yet no traces of any morbid lesions 
are found about the heart at the post-morte^n examination. The 
foramen ovale, on account of this same fallacious supposition, has also 
received altogether too much attention, and it was a matter of no con- 
sequence, when a probe could be passed from one auricle into the 
other, whether the valve was perfect or not. 

The only test-bearing reason for the cyanosis is to be foimd in an 
imperfect oxidation of the blood in the kmgs, combined with a stasis 
in the peripheral venous system. But this process may be produced 
by various conditions ; either an impediment exists at the left side of 
the heart, and conjointly with this there is stagnation of the blood in 
the pulmonary veins, or the supply of blood to the lungs is diminished 
in consequence of a stasis in the right side of the heart, and hence 
less blood is arterialized, or the circulation meets with impediments 
in the lungs, the eflfects of structural lesions, or, lasth', the inhaled air 
is poor in oxygen, and in that case the blood is likewise but imper- 
fectly oxidized. The blood may also become so altered in consistency 
that its flow wUl thereby be retarded, and this is especially applicable 
to the inspissation of the blood in cholera. Thus we see that the 
causations of cyanosis are tolerably numerous, and are by no means 
solely to be sought for in mechanical alterations of the heart. 

The degrees of cyanosis vary exceedingly, and fluctuate between a 
slight bluish discoloration of the lower eyelids and a bluish redness of 
the whole body, and all supervening congestions produce an aggrava- 
tion of the existing cyanosis. Too high and too low temperatures, 
excitement, crying, laughing, bodily exertions, are therefore the most 
frequent causes of this aggravation. 

When children Avith congenital malformations of the heart survive 
the first few years, various other symptoms of disturbance of the cir- 
culation become superadded. Almost all of them suffer from imper- 
fectlj'-developed pectoral muscles and pigeon-breast. The extremities 
are always cold and moist, very much like the skin of a frog, the tips 
of the fingers swell up bulbous, over which the nails, curved like claws, 
project ; the cutaneous veins are preternaturally large ; the patients 
are unable to exert themselves in any manner, whether to run or 
climb, or to cry continuously, for all these efforts cause them severe 
pain in the praecordia, dyspnoea and palpitations. Haemoptysis, also, 
in rare instances, is observed in larger children ; (;pistaxis, on the con- 
trary, is a sj-mptom which occurs tolerably often, and as a rule gives 
momentary relief. Finally, general dropsy of the cellular tissues and 
of the serous sacs, with which albuminuria becomes associated, ter- 
minates the distressful existence of these children. 

The physical examination of congenital cardiac malformations is 



DISEASES OF THE ORGANS OF CIRCULATION. I99 

at^^ended by extraordinary difficulties. Hypertrophy of the heart is 
alraost unexceptionably demonstrable, and is usually due to a marked 
enlargement of the right side of the heart. In this condition the 
heart's impulse is felt over a larger space, and stronger than usual. 
Distinct cardiac murmurs can seldom be elicited by auscultation ; in 
most instances a confused sound is only heard instead of the one or 
the other, or even in place of both cardiac sounds. Prolonged loud 
murmurs allow one to conjecture the existence of a marked abnormal 
communication between the cardiac moieties, a perforation of the sep- 
tum for example ; a strong systolic murmur heard most distinctly over 
the pulmonary artery indicates a constriction of this vessel, one of the 
most common malformations that occur. Sometimes, however, the aus- 
cultatory phenomenon is not adaptable to the one or to the other evil, 
and no nearer approach to an accurate diagnosis can be made than of 
congenital defect in general. The periods of the first and second 
dentition, according to statistical compilations by Friedberg and Ah- 
erle^ are especially dangerous for children with congenital defects of 
the heart. Out of 139 cases, 53 died in the first year, 51 between 
the second and eleventh year, 30 between the eleventh and twenty- 
fifth, and 5 only attained to an age of over forty-four years. 

Treatment. — A direct treatment, of course, is altogether out of the 
question ; we have to limit our efforts to the prevention of all j)ossible 
injuries, and to institute an appropriate dietetic reghne. The restric- 
tions concerning the necessary rest are easily enforced in these chil- 
dren, for they are soon taught by experience how injurious and pain- 
ful any accelerated action of the heart is to them. As regards the 
diet, no particular precautionary measures need be prescribed ; all 
heating and alcoholic drinks, however, must be absolutely prohibited. 
Warm clothing is extremely advantageous in these cases, and a flan- 
nel shirt should therefore be particularly recommended to be worn 
next the skin. All antiphlogistic treatment, with calomel, leeches, 
cantharides, etc., must under all circumstances be avoided, for dropsy 
and the fatal end are perceptibly accelerated by it. Active conges- 
tions, which in these cases are liable to occur extremely often, must be 
relieved by the external application of cold, acidulous drinks, and 
strict diet. 

If the children come asphyxiated into the world, the methods of 
animation already recommended for asphyxia should be resorted to, 
but in these cases they almost always prove fruitless. 

(2.) EKDOCARmxis, Pericarditis, and Rheumatismus Acutus. — 
We include here three morbid pictures in one frame, which anatomo- 
pathologically have no similarities whatever to each other ; clinically, 
however, they can scarcely be separated, if it is desired to avoid tlie 



200 



DISEASES OF CHILDREN. 



numerous repetitions which must occur in describing the individual 
iterations separately. Added to this, these morbid conditions are 
extremely rare in children, and it hardly seems necessary to give a 
very exhaustive account of them. 

Symptoms. — We commence with the symptoms of acute rheuma- 
tism, and then allow the most frequent complications, endo- and peri- 
carditis, to follow : 

FJieumatismus acutiis.— Acute rheumatism of children differs but 
little from that of the adult, only its course is shorter, and the affec- 
tion, as a rule, less intense. The youngest child that I have had to 
treat, for well-marked acute rheumatism, with endocarditis, was one 
year and nine months old, and after three months succumbed to dis- 
ease of the heart. This is a very rare case, for in all the text-books it 
is stated that children of six years and over are only liable to 
this disease. Many affections, which by the laity are denominated 
by the vague name of "growing fever " (Wachsfieber), belong to this 

condition. 

Intense fever is always present at first, the skin becomes burning 
hot, the thirst great, the pulse enormously accelerated, and great rest- 
lessness and sleeplessness supervene. This intense fever at the ut- 
most lasts eight to ten days ; it then gradually subsides, and only 
when pernicious comphcations have become superadded, particularly 
affections of the heart, will it continue for an indefinite time and with- 
out interruption. In most instances the patients are very pale and 
collapsed, have a remarkably sad, painful expression of countenance, 
and a lethargic appearance ; they keep the affected joint in the ut- 
most possible state of quiescence, while the free extremities, on ac- 
count of the intense fever-heat, are incessantly restless and agitated.^ 
The essentiality of the disease consists in a swelling of the vari- 
ous joints, predominantly those of the lower extremities, which are 
affected in the same manner as in the adult. Touching and still 
more the moving of the diseased members is extremely painful, and 
the patients, with an expression of the utmost anxiety in their coun- 
tenances, will guard over and admonish against every approach to the 
painful joint. The swoUen parts are always reddened at first; the 
redness, however, disappears before the tumidity does. The knee-joints 
are most frequently affected, next in order of frequency follow the 
joints of the ankles, then those of the upper extremities, and lastly the 
spinal column. 

These swellings of the joints never pass over into suppuration ; 
they abate completely, and disappear without leaving any traces of 
the disease beliind them ; in some instances a slight weakness and 
painfulness, on using the extremity, will be the only evidences of the 



DISEASES OF THE ORGANS OF CIRCULATION. 201 

previous existence of the malady. The pathognomonic sign of the 
affection is its wandering, or its alternating, from one joint to the 
other. Only extremely rarely is the process completed with the simul- 
taneous implication of several joints ; usually, in a few days after the 
swelling of the joints first affected has declined, new ones will be at- 
tacked with the same severity and run a similar course, and this may 
be succeeded by a second and even a third accession. 

The general symptoms correspond to the severity of the fever. The 
appetite is very much abridged, or completely gone, the stools are re- 
tained, the urine is dark-colored, rich in uric acid, and voided in small 
quantities only. The patients perspire very much, and are thickly 
studded with miliaries. 

The diagnosis of acute rheumatism is very easy, since it almost 
wholly attacks older children, who are already able to give a rational 
account of their sufferings. It can only be confounded, in its incipiency, 
with the prodroma of an exanthema, or with typhus fever, where also 
very severe pains in the knee and ankle joints occasionally occur. The 
latter, however, are recognized by the facts that the joints do not 
swell, and that slight pressure or passive motion does not particvilarly 
aggravate the pain, which is always the case in acute rheumatism. If 
it is at all possible to confound the disease under consideration with 
scrofulous arthrocace, with tumor albus, then this can onl}'- happen in 
its incipiency, and the error can continue but a few days, as no wander- 
ing of the malady from joint to joint occurs in the latter affection, and 
its course is of a totally different and chronic form. 

Simple acute rheumatism, without any complication, has a duration 
of fourteen days at the utmost. But when it is complicated with car- 
diac affections, as is the case with at least one-third of all the cases af- 
fected, its duration will then be indefinitely prolonged, and a fatal 
end may occur even after a sickness of many years. Under the head of 
complications (a.) Endocarditis and (b.) Pericarditis deserve a special 
consideration. 

(a.) Endocarditis. 

Pathological Anatomy. — The excellent investigations of JOuschJca 
have established the fact that the endocardium is composed of the 
same number of layers as the vessels. The superficial surface is formed 
by a thin stratum of pavement-epithelium, which must be regarded as 
the direct continuation of that of the vessels. Then follows a layer of 
extended longitudinal fibres ; next, one of very fine elastic fibres, which 
frequently interlace with each other, analogous to the contractile coat 
of the vessels ; and, finally, a layer of connective tissue unites this 
elastic coat with the muscles of the heart. The vessels and nerves arc 



202 DISEASES OF CHILDREN. 

found almost entirely in this connective tissue, and are but little in con- 
tact with the elastic fibres, which accounts also for the circumstance that 
a true exudation can only take place in the former. The 'exudation, 
however, soon forces the suj^er-lying- coats aside, and makes its appear- 
ance in the cavity of the heart, on the other side ; it also attacks the 
subjacent layers of the cardiac muscle, so that a slight degree of myo- 
carditis always accompanies endocarditis. Red spots, according to 
Z/uschka^ are at first observed on the endocardium ; the superficial sur- 
face as yet is stUl perfectly smooth ; this smoothness, however, soon 
disappears, the superficial surface becomes rough, and now the exuda- 
tion under the microscope exhibits entire and destroyed epithehum- 
cells, exudation-corpuscles, and fibre-elements. The roughened places 
on the endocardium soon arrest some fringes of fibrine, from the on- 
ward-flowing current of blood, and thereby acquire a flocculent ap- 
pearance. Tliis endocarditic exudation, according to J3amherger^ may 
undergo the following metamorphosis : 

(1.) The exudation may be completely absorbed ; this, however, 
only seems to be possible in very thin layers that have not yet pene- 
trated through the epithelium. 

(3.) In most instances it does not disappear entirely, but produces 
permanent alterations upon the inner surface of the heart. The most 
common morbid appearances of this kind met with are white con- 
densed places, a condition that has been called tendinous spots (Sehnen- 
flecke), which are always disposed to atrophy, and undergo cicatricial 
contraction, and now, in case these occur on the valves or in their im- 
mediate vicinity, will cause them to shrink or alter their attitude and 
insertions. Thus, endocarditis is the main cause of subsequent cardiac 
disease. In other cases, the endocarditic exudation has the dispo- 
sition to degenerate into poh^Doid extuberations, and then will pos- 
sess many points of resemblance to pointed condylomata, and, in 
consequence thereof, have even been falsely regarded as true manifes- 
tations of syphihs. 

(3.) It has become evident, mainly through Vh'choio's indefatiga- 
ble researches, that some of the already coagulated portions of the ex- 
udation may also be torn off from the endocardium, a^d washed away 
by the current of the blood, and in this manner thiombosis form in 
different parts of the body. The most common sitcb of these thrombi 
are in the spleen, next in the kidneys and brain. Death almost inva- 
riably ensues from such a displacement of the thrombi. 

Symptoms. — "SMien the endocarditic exudation is so deposited that 
it cannot materially influence any of the valves, it will not be possible 
to ascertain its existence by a physical examination ; moreover, the 
functional phenomena are so variable and so imperfectly described, even 



DISEASES OF THE ORGANS OF CIRCULATION, 203 

by large children, that it seems almost impossible to form a diagno- 
sis. Generally, however, extuberations form upon the valves, and then 
distinct physical alterations ensue. 

The left side of the heart is affected much oftener than the 
right ; and the mitral valve, in fact, most frequently of all. Not only 
the deposits upon the valve itself, but also those in the vicinity of the 
columnee carnge and columnjB papillares, are capable of producing a 
distortion of the valve, or causing it to atrophy, and thus effect its in- 
sufBciency. We therefore have, as the most common physical signs, a 
systolic murmur, in place of the first sound of the heart, heard with the 
greatest distinctness at the apex of the heart, less distinctly over the 
aorta, and not at all over the carotids. The right side of the heart 
soon becomes consecutively enlarged, so that the dulness in the pras- 
cordia extends over a larger space, and the heart's impulse is felt corre- 
spondingly stronger, and over a larger area. If the extuberations around 
the ostium venosum of the left ventricle * become very numerous, a 
stenosis will then also take place at this ostium, and thus produce a di- 
astolic murmur ; this condition, however, seems to be exceedingly rare. 

The semilunar valves of the aorta may likewise become involved 
in the endocarditic process, and, through shrinking and perforations, be- 
come insufficient. But, the more common phenomenon observed on 
these valves is, their becoming covered with vegetations, and thus giv- 
ing rise to a stenosis at the ostium arteriosum. A systohc murmur is 
likewise heard in this case, but it is most distinct over the aorta, 
and is plainly propagated into the carotids. 

The right side of the heart is much more rarely attacked by endo- 
carditis than the left, and the murmurs which occur there must be in- 
terpreted in the same manner as in the case of the left ventricle, but, 
in this case, the stagnation of the blood in the veins ©f the neck is 
much more pronounced than in valvular disease of the left ventricle. 

The functional symptoms of endocarditis vary exceedingly. The 
pain is seldom regularly present, or very severe ; oppression of the 
chest, anxiety and incessant restlessness, so far as the acute rheu- 
matism will allow, are much more constant. Still, all these symptoms 
are more pronounced in pericarditis than in endocarditis. Palpitation 
of the heart is always present, and is increased on exertions, such as 
crying and bodily exercise ; and a peculiar nervous dyspnoea, or short- 
ness of breath, invariably comes on at the same time, which at first 
reveals no demonstrable mechanical causes ; later on, however, it is 
satisfactorily explained by the stagnation of the blood in the left auricle. 

Children laboring under endocarditis always have fever, and, if 
they have already got rid of the fever which accompanied the acute 
* [Auriculo-ventricular opening.] 



204 DISEASES OF CHILDREN. 

rheumatism, will again be attacked by violent febrile symptoms on the 
appearance of this compHcation. They last for an indefinite period, 
often for many weeks ; to their intensity, and not to the commencing' 
cardiac defects, is the serious emaciation of these children in greater 
part due. Furious delirium occasionally comes on, and when con- 
jointly with this the spleen is also enlarged, a condition that is very 
apt to occiu" in a marked degree when emboU form in it, then this 
group of symptoms may very readily be taken for that of typhus fe- 
ver. Secondary symptoms, produced by the displacement of emboli, 
are, on the whole, extremely rare in children. I have so far only once 
found embolic formations in the spleen and kidneys ; the child was 
eight years old, and he died from endocarditis. 

The diagnosis of endocarditis is almost always attended by the 
greatest difficulties ; and this fact must especially be taken into con- 
sideration here, that not every blowing murmur of the heart indicates 
endocarditis, for childi'en laboring under febrile diseases very often 
and very quickly get angemic murmurs, which disappear spontaneous- 
ly as soon as convalescence commences. This is particularly observed 
in cases where abstraction of blood, even only locally, has been prac- 
tised ; and, as this remedy is often also resorted to on account of the 
rheumatic pains, anasmic murmurs are therefore apt to supervene as 
the effect of acute rheumatism. 

In addition to a blowing murmur, a more extensive impulse, an 
enlargement of the heart demonstrable by greater dulness on percus- 
sion, acceleration of the pulse, and dyspnoea, are requisite for the pur- 
pose of correctly diagnosticating an endocarditis. The terminations 
of this disease are entire recovery, complicated sequelte, or death. 
Complete recovery from a tolerably well-developed endocarditis must, 
in fact, be accounted as one of the greatest rarities, because the resi- 
due of the exudation commonly produces alterations of the valves, 
and herewith cardiac disease. Death seldom takes place at the climax 
of the disease by exhaustion or the formation of emboli ; in most in- 
stances the patients waste away under incessant fever, accidental diar- 
rhoea, or bronchitis, or perish by lobular pneumonia. The cardiac 
afi"ections which originate from this disease often develop themselves, 
after many months, by the shrinking of the exudation, and exercise 
more and more influence iipon the circulation, till finally the cardiac 
sequel, as such, makes itself manifest, and after a shorter or longer 
duration brings about a fatal end. 

(b.) Pericarditis, 

Pericarditis has been diagnosticable with certainty only since the 
discovery of the pericarditic friction-sound by ColUn, in 1824. But 



DISEASES OF THE ORGANS OF CIRCULATION. 205 

the diagnosis even at the present day is still extremely difficult and 
imperfect, as will be perceived from the following remarks : 

Pathological Anatomy. — A general and a circumscribed pericardi- 
tis, according to the extent of the affection, is spoken of. But pericar- 
ditis possesses the utmost disposition to spread, and the general ia 
therefore more frequently met with than the circumscribed. The 
morbid lesion may just as readily begin on the parietal as on the vis- 
ceral coat ; and on either an injection, immediately followed by plas- 
tic exudation on the surface, takes place early in the course of the 
disease. 

Different forms of pericarditis are distinguished according to the 
nature of the exudation. 

(1.) The fibrinous exudation. In this form, the external surface of 
the heart and the pericardium are thickly coated with a shaggy, yel- 
lowish-white membrane, and are either entirely or partially united with 
each other. This exudation is capable of becoming organized, and in 
it capillary vessels soon become developed, which are often the means 
of occasioning small extravasations. Conjointly with this organized 
membrane there is always a greater or lesser quantity of fluid effu- 
sion, which, on account of the presence of dissolved shreds, and flat 
gelatinous particles of lymph, appears yellomsh, turbid, and flocculent. 
Generally, this fluid portion of the exudation is subsequently ab- 
sorbed, when the firm inflammatory membranes will be everywhere in 
contact with each other, and now either become firmly and intimate- 
ly united with each other, or, when the plasticity is but shght, they 
will be ground off against each other, and almost entirely disap- 
pear. The condition denominated tendinous spots (Sehnenflecke) 
must be regarded as a residue of these processes, and the extraor- 
dinary frequency with which they are met in autopsies might readily 
convince us that partial pericarditis is often overlooked. Ossification 
of the exudation — a condition that is occasionally observed in the 
autopsies of adults — is not known, to my knowledge, in the Pasdia- 
trica. 

(2.) The purulent ichorous exudation. When the fluid effusion, 
conjoined with the fibrinous membranes, is of large quantity, and 
has a purulent consistence, the pericarditis is denominated piunilent. 
No actual boundaries, however, exist between this and the preceding 
form, for in both alike liquid and membranous efiiisions occur togeth- 
er. It may very readily happen that a pericarditis, wliich primarily 
must have been described as purulent, after a while, when the liquid 
part of the exudation has been absorbed, becomes fibrinous. In new- 
bom children, on the contrary, the ichorous pyajmic pericarditis is 
almost exclusively met with. This form will be desciibed more minutely 



206 DISEASES OF CHILDREN. 

in connection with pyasmic pleuritis. It never occurs by itself, but al- 
waj'S in common with pleurisy or peritonitis, and is distinguished by be- 
ing tolerably thin, of a broAvnish-red color and ichorous odor, and also 
by the flakes of lymph suspended in it not being yelloAvish-white, but 
of a grayish-brown color. Phlebites of the umbilical veins and putres- 
cence of the navel, as will be shown further on, are generally found 
in these cases, 

(3.) The tuberculous exudation. Tuberculous pericarditis — not- 
withstanding so many children perish from tuberculosis — is a very 
rare condition. The tubercles on the pericardium are mostly larger 
than miliary tubercles in the lungs, and are sometimes found isolated, 
but sometimes again so close together that they form a rough, hilly 
membrane, the tuberculous character of which is not perceived at 
first sight. MacroscopicaUy, however, they are easily recognized by 
the friability and the greater ease with which they are lacerated than 
the agglutinated membranes ; onlcroscopicalli/^ by the tuberculous de- 
tritus. 

Symptoms. — The pathological picture of pericarditis, commonly 
delineated in the text-books, applies but imperfectly to children, for 
the phenomena are so variable that, strictly speaking, a description 
with universally adaptable symptoms must in reality be entirely 
renounced. They are often very mild, and completely masked 
by the other concomitant diseases — acute rheumatism, pyaemia, 
Bright's disease, and tuberculosis ; again, they are often very striking, 
and manifest themselves by great oppression of the chest, severe 
pain, dyspnoea, raj^id pulse, fainting, delirium, and cyanosis. The 
physical examination always supplies the most important cardinal 
points. 

On inspecting the denuded chest, the heart at the commencement 
of pericarditis is seen to beat harder than usual against the expanse 
of the thoracic walls, and occasionally a slight irregularity of the 
rhythm is already observable. Later, when the exudation increases 
in amount, and particularly when the fluid part thereof greatly pre- 
ponderates, the heart becomes displaced toward the left and up- 
ward, and wiU beat correspondingly against the thoracic walls more 
toward the left and higher up. But if the efliision becomes still 
greater, then the most characteristic sign comes on, namely, the 
heart'' s impulse can neither be seen nor felt. The pericarditic friction- 
sound, when it is heard very loudly and very distinctly, may also at 
times be discovered by palpation. 

Nothing abnormal can be detected by percussion, when the exu- 
dation is small in quantity, but, when the eflFusion is hquid and of a 
large amount, a dulness over an extensive surface, having the form of a 



DISEASES OF THE ORGANS OF CIRCULATION, 207 

blunt pyramid, the apex of wliicli is directed upward, is obtained. 
The dulness upward, which may reach as high as the third and even 
the second costal cartilage, is especially characteristic of this condi- 
tion, and materially facilitates the diagnosis. It must not be forgot- 
ten that very decided pericarditis, in which the exudation is predomi- 
nantly of the membranous form, cannot be ascertained at all by per- 
cussion. 

By auscultation, slightly invigorated cardiac sounds are at first 
distinguished, which occasionally only deviate slightly from the nor- 
mal rhythm. A friction-sound, however, soon becomes perceptible 
over one or the other portion of the dulness, which at first may 
be extremely difiicult to differentiate from an endocarditic bruit / 
later on, however, it distinctly manifests itself as a friction-sound. 
It will resemble, according to its intensity, a slight grazing, rasp- 
ing, gnashing, or scratching, and is particularly distinguished by 
the fact that it is usually neither systolic nor dyastolic, but is heard 
between the two cardiac sounds. It is often very difficult to dif- 
ferentiate it from the endocarditic murmurs, and then it will al- 
ways be necessary to examine the patients while asleep ; and in this 
connection it may be well to observe that the precaution should 
be taken to allow them to fall asleep in such garments as can be 
readily opened in front, and will permit the thorax to be exposed. 
The main difi"erences are always that the pericarditic friction sound 
is limited to an extremely narrow space, and never extends as far as 
the endocarditic murmurs ; that it is neither systolic nor diastolic, 
and that it often vanishes suddenly only to reappear at an adjacent 
spot, or to remain absent permanently. In consultations this may 
sometimes be the means of causing difi"erent opinions to be enter- 
tained in regard to the disease. 

In the early stage of the disease the pulse is strong, rapid, and 
difficult to be compressed ; later, it generally becomes small and 
unrhythmical, and is then easily compressed. In cases of large peri- 
carditic effusions, distinct undulating movements are observed on the 
jugular veins, and even a bulging of the veins during the systole, 
and a subsidence during the diastole takes place. At the beginning 
of the systole the tricuspid valve becomes closed, and the right auricle 
then dilates ; but, since the dilatation, on account of the existing 
effusion, cannot take place properly, a stagnation of the blood in the 
vessels consequently results, and a visible distention of the jugular 
veins is accordingly produced. Catarrh of the bronchi, and, indeed, 
also, partial compression of the right lung, are almost always asso- 
ciated with this condition. 

The functional and general disturbances are extremely variable, 



208 



DISEASES OF CHILDREN. 



as has already been remarked at the commencement of this delinea- 
tion, and depend much more upon the complications of endocarditis 
than upon this affection /?er se. Its terminations are either recovery, 
of course only in rare instances, attended by a sudden disappearance 
of the friction-sound, or death, which often ensues quickly and unex- 
pectedly, or finally sequelte, such as universal adhesions of the heart 
with the pericardium, dilatations of single chambers, disease of the 
cardiac muscle proper, and, as effects of these processes, manifold dis- 
turbances of the circulation. 

Treatment. — Acute rheumatism cannot be aborted, probably not 
even shortened, in its duration; neither calomel, tartar emetic, ab- 
straction of blood, nor the cold-water treatment, produces any marked 
favorable effect upon it. Under such circumstances, we have no other 
alternative but to initiate a symptomatic treatment, in which morphine 
plays the greatest role. A proper dose of morphine, administered to 
the patients in some syrup, will procure them the necessary rest ; the 
process, however, is in no way modified by it. The affected joints 
should be rubbed with olive-oil, and thickly covered with cotton 
wadding, in order to protect them against all kinds of external 
violence. 

I never treat endocarditis and pericarditis, which complicate acute 
rheumatism, strictly antiphlogistically ; in well-nourished children, a 
few doses of calomel, at the utmost, may, perhaps, prove beneficial as 
an antifebrile remedy. Mild counter-irritants, such as sinapisms, dry 
cups, etc., may prove beneficial. Pysemic pericarditis of the new-born, 
of course, always terminates fatally, and, therefore, calls for no special 
treatment. The consecutive cardiac affection requires an extremely 
cautious, strict regime, as has already been more minutely pointed 
out in the preceding section, in the treatment of congenital affections 
of the heart. 

(3.) Hydeopericakdhjm — Dropsy or the Peeicakdium:. — Dropsy 
of the pericardium, alone by itself, occurs only in defects of the heart, 
where the disturbances of the cu-culation then manifest themselves 
earlier on the pericardium than on the pleura and peritonaeum. In 
most instances, however, it is complicated with serous effusions into 
the aforesaid sacs, and appears as the closing scene of dropsy, with 
usually a rapidly fatal end. In children, nephritis after scarlatina is 
almost the only cause of pm-e dropsies. 

Pathological Anatomy. — A light-yellow, clear effusion, varpng 
from one to fovu: ounces, is fovmd in the pericardium, possessing the 
chemical properties of other serous effusions, i.e., that of a diluted 
serum of the blood. The pericardium, in contradistinction from puru- 
lent pericarditis, is, \vith the exception of a slight serous infiltration. 



DISEASES OF THE ORGANS OF CIRCULATION". 209 

perfectly intact, neither covered with pseudo-membranes nor abnor- 
mally adherent anywhere. The muscular coat of the heart itself, as 
in all other dropsical effusions, has more of a yellowish than a red 
color. 

Symptoms. — Slight pericarditic effusions cannot be diagnosticated, 
and, probably, give rise to no symptoms, as the pericardium, even in 
the physiological state, contains some fluid, and the quantity of this 
fluid is subject to no inconsiderable variations. In extensive effusions, 
the symptoms of pericarditis, just sketched, will be distinctly ob- 
servable. Great oppression, and even orthopnoea, comes on ; the jugu- 
lar veins swell with every systole, and subside again with every dias- 
tole. The integument on the well-known places becomes cyanotic and 
its temperature lowered. As the pure hydropericardium is, in every 
instance, preceded by dropsies in other parts of the body, and which, 
perhaps, still exist, its morbid picture is, therefore, materially obscured 
and obliterated ; this is especially applicable to the respiratory dis- 
turbances. The physical signs are the same as in pericarditis, only 
stUl more pronounced, and easier to be elicited, for these patients are 
less severely affected in their general condition, and, therefore, are 
more tranquil than those suffering from pericarditis. The praecordial 
region bulges slightly, the impulse of the heart is weak, or entirely 
imperceptible, the pulse is small, the dulness on percussion upward 
very marked and flat. One sign only of pericarditis never occurs here, 
namely, the friction-sound, for its cause, roughened walls, plastered 
with membranous exudations, never exists here. The terminations of 
hydropericardium differ according to its cause. Those effusions which 
supervene upon diseases of the heart always terminate fatally, while 
those ensuing from scarlatina are capable of being absorbed under 
proper treatment. 

Treatment. — The diuretic treatment, as in all dropsies, is also here 
the one most indicated, and the pure roob * juniperi, without any kind 
of vehicle, is tolerated longest and best of all the diuretic remedies. 
Derivatives upon the alimentary canal should not be tried in this class 
of patients, because they always disturb the digestion, and a cure of 
dropsy is only possible when the metamorphosis of the tissues goes on 
properly. Nor do derivatives upon the skin, by repeated vesications, 
seem appropriate, on account of the great pain they produce ; still 
less can they be used in cliildren with nephritis, for the cantharides 
keep the kidneys in a constant state of irritation. Paracentesis of the 
pericardium, it is true, is recommended, in many works, for the sake 
of completeness, as a last resource, but, so far as I am aware, has 
never yet been performed in children's practice. 

* [See note to page 191.] 



210 DISEASES OF CHILDREN. 



^.—ARTERIES AND VEINS. 



Diseases of the arteries never occur in cliildren, and the results of 
atheromatous afiections of the arteries, which are scarcely ever missed 
in the autopsies of older individuals, are never obsen^ed in those of 
the former. The only condition of which some notice ought to be 
taken here is, an anomalous termination of the radial arteries, which, 
in some seriously sick or anaemic children, may be the fault of ha\4ng 
caused an unfavorable prognosis to be given. Hence, in cases of re- 
markable smallness, or complete absence of the radial pulse, it is al- 
ways necessary to ascertain the condition of other arteries, the carotids 
and temporal, before a conclusion can be formed upon the fulness or 
emptiness of the vascular system. Tlie erectile tumors, as a stepping- 
stone in the study of the diseases of the veins, may find a place here. 

(1.) Erectile Tumors [Ncevus Va^culostis, Arterial Teleanrjiec- 
tasis). — Symptoms. — By erectile tumors we understand a dilatation 
of the capillaries, a condition which occurs particularly on the face, 
eyehds, lips, and neck. This disease of the capillary vessels some- 
times affects those of the cutis, sometimes those of the subcvita- 
neous cellular tissue, and then again both, at the same time, to a 
greater or less extent. In the first case, we have a red elevation 
of the integument, of the color, and often, also, of the shape of a rasp 
berry ; in the latter, a slightly doughy tumor, the integument cover- 
ing which is either in a perfectly normal condition, or likewise per- 
meated by dilated vessels. Generally, these vascular dilatations are 
congenital ; their growth, however, does not always progress in exact 
relation to the development of the entire organism, but surpasses it 
considerably, so that a small teleangiectasis, at birth only of the size 
of a pin's head, at the end of a year may have attained to that of a 
pea, or even of a hazel-nut. This fact is universallj- kno^vn ; on the 
other hand, most physicians are not sufficiently aware of the spon- 
taneous termination of these erectile tumors and vascular moles. The 
general opinion is that, if no operative assistance is rendered, they 
will continue to grow, and attain to serious dimensions, and yet the 
reason why they are so rarely met with in adults, and comparatively 
often in children, has never been satisfactorily explained. The true 
reason for this circumstance is, that most of them grow smaller spon- 
taneously, and ultimately disappear altogether, although nothing, in 
the shape of an operative procedure, had been resorted to against 
them. This spontaneous atrophy, after the manner of infantile cutane- 
ous warts, sufficiently distinguishes njevus vasculosus from malignant 
neoplasms. 

Erectile tumors, the integument of which is almost normal, are 



DISEASES OF THE ORGANS OF CIRCULATION. 211 

easily diagnosticated by the facts that they disappear under the press- 
ure of the finger, become tenser and larger during crying and pressing, 
sometimes pulsate slightly, and on auscultation allow a buzzing noise 
to be heard. 

Pathological Anatomy. — When such a tumor is cut open on the 
cadaver, it collapses very much, and gives exit to a tolerable quantity 
of red serum. On closer investigation it is seen to be composed of 
merely dilated, excavated capillaries, which freely communicate with 
each other, and thus present a spongy formation. This is also the 
reason why erectile tumors are materially reduced in size by com- 
pression. If it is fetill further examined microscopically, there will 
be found numerous longitudinal and transverse sections of capillaries, 
and occasionally it has the appearance of small, pouch-like excavations 
in the vessels, as if the capillaries terminated with bulbous dilatation. 
Between these vessels perfectly normal connective tissue is seen. 

Treatment. — The treatment of cutaneous nsevi is different from 
that of erectile tumors of the subcutaneous cellular tissue. The 
raspberry-colored spots of the skin on the forehead, eyelids, etc., are 
best, and in the simplest manner, removed by vaccination. For this 
purpose the naevus is punctured ten to twenty times with a needle 
dipped in vaccine matter, when a few drops of blood will always 
escape, and if nothing further is done the operation will prove entirely 
fruitless, for the vaccine lymph has oozed out with the blood. But 
if these punctures are quietly allowed to drain off the blood, then 
cleansed with a little cold water, and once more covered with a layer 
of vaccine matter, all, or nearly all of the punctures will take. On the 
fifth day the nsevus displays many elevated bluish-red pustules, which 
soon become confluent, and begin to dry up by the eighth or ninth day ; 
after the crust has fallen ofi", a bluish-red cicatrix will at first remain be- 
hind, which subsequently fades very much.* If a child that has already 
been vaccinated comes under treatment for nsevus, this procedure, of 
course, will prove entirely useless ; in such a case the nsevus may be 
made to disappear entirely, or, at least, be cut up into single smaller 
ones, by producing deep, penetrating pustules, by the aid of a plaster 
composed of one part of tart, stibiat. and three of beeswax, smeared 
upon a piece of linen and worn for four or six days, at the end of 
which time small ulcers will have formed, which heal by granulation. 
The remnants of the naevus may again be covered with the plaster 
without the least detriment. Large flat n^evi may also be made less 
noticeable by tattooing. Ten or twelve needles are thrust through a 

* [Dr. Loines informs me that he has cured many nrevi by vaccination, and that 
the phenomena, in the absence of complications by violence, are almost identical 
with those of ordinary primary infantile vaccination.] 



212 DISEASES OF CHILDREN. 

small plate of cork-wood, and with tliis instrument the naevus is punc- 
tured all over, after which magnesia usta, or oxide of zinc, is rubbed 
in the fresh puncture-wounds. From this mixing of red and white 
a rose-color ensues, which contrasts but slightly with the normal color 
of the surrounding integument. 

It is always well to bear in mind, before any intense cauterizations 
are resorted to with Vienna paste, chloride of zinc, sulphuric acid, etc. 
— from which large gangrenous ulcerations and disfiguring cicatrices 
sometimes ensue — that many naevi in time disappear spontaneously, 
and at the utmost leave behind them a slightly redder-colored spot on 
the skin, which certainly disfigures less than the large, radiating, con- 
tracted eschars that result from the operations. I have established it 
as a rule for myself, not to treat surgically any cutaneous naevi w^hich 
cannot easily be surrounded by two curved incisions, and the lips of 
the wound accurately united through the bloody suture. 

The case is totally different with the subcutaneous erectile tumors, 
which, on the whole, are far more infrequent than teleangiectasis 
of the cutis. Through spontaneous ruptvn-e or slight injuries they 
may give rise to serious haemorrhages that may endanger life, and 
their treatment should not be deferred on that account alone. In 
some instances it has, indeed, been possible by steady compression to 
cause such tumors to disappear, but for this method a great deal of 
time and patience is necessary, and, in addition, the presence of a 
firm, bony substratum ; otherwise the attempt at compression will 
prove entirely fruitless. Formerly the Hgature was principally em- 
ployed in the removal of these subcutaneous capillary extuberations ; 
a needle armed with a double ligature, or, still better, a narrow tape, 
was drawn through the base of the tumor, then tied in two sections 
at opposite points, and allowed to ulcerate its way through ; of late, 
the galvano-caustic has rendered essential service in these cases. 
For this purpose several platinum w^ii'es are introduced into the base 
of the tumor in opposite directions, at a distance of two or three lines 
from each other, and brought to a white heat by the aid of the bat- 
tery, by which coagulation of the blood, suppuration, ulceration, and 
finally healing, are achieved. 

(2.) Thbombi in the Sinuses op the Dura Mateb. — Many in- 
restio-ations have been made in this direction since the time Virchow 
developed and cultivated the study of the formation of thrombi, and 
the pathological condition in its signification upon the course of the 
disease has come to be more appreciated. Thus, Gerhard fotmd 
thrombi in the sinuses of the brain seven times in the autopsies of 
ninety-six children, and all of those seven children died from profuse 
diarrhoea, attended by cyanosis, coma, and convulsions. 



DISEASES OF THE RESPIRATORY ORGANS. 213 

But there is the greatest difficulty in determining the ages of these 
thrombi. Wliether a thrombus has formed before death, in the 
mortal agonies, or only after death, cannot always be decided. The 
cardinal points which will lead us to settle this question correctly are, 
the arrangement of the layers of the thrombi, their central softening, 
and their adhesion to the walls of the veins ; whether they are of a 
yellow or red color is a matter of no such great importance. It seems, 
however, that they are not pathognomonic of the atrophy of children, 
for I have often missed them, and in other cases found red, fresh 
thrombi, which undoubtedly only originated after death. This con- 
dition, therefore, has but slight clinical importance. 



CHAPTER IV. 

DISEASES OF THE RESPIRATORY ORGANS. 
A.— NASAL CAVITIES. 

As the diseases of the mouth have already been spoken of in con- 
nection with those of the digestive apparatus, there remain only for 
consideration those of the nares. The method of examining the nares 
is a simple one, and offers but few difficulties, since it is limited en- 
tirely to an inspection or exploration, by the aid of a probe or catheter. 
Wtntrich has found that the permeability of the nasal passages may 
be confirmed by percussing the larynx. When, the mouth being closed, 
percussion is performed over the larynx, the tympanitic percussion- 
sound that is produced by it becomes dull if one of the nasal open- 
ings is closed, and still more decidedly flat when both nares are com- 
pressed. Now, if, by the closing and reopening one or both nares, the 
tympanitic sound does not change in intensity, it may be regarded as 
proof that the affected nostril is occluded at some point higher up. 
But this method of examination can only be exercised in old chil- 
dren — those that will close the mouth when ordered to do so, and who 
Avillingly allow the nares to be compressed, and the larynx to be per- 
cussed. Such children will also snuffle in and out when so ordered, 
and the permeability of the nasal passages may in this manner be 
ascertained more conveniently than by percussing the larynx. 

(1.) EnsTAXis — Bleeding of the Nose. — Epistaxis, as, in fact, 
all hasmorrhages, is produced by a rupture of vessels ; in this case, of 
the capillaries of the mucous membrane of the nose. 

Etiology. — The causes are divisible into local and general. The 
local are injuries of all kinds, blows, contusions, lacerations, etc. Still, 
15 



214 DISEASES OF CHILDREN. 

even here, the individual disposition is not to be lost sight of, for the 
various injuries produce entirely different effects, according to the ex- 
isting disposition to bleed from the nose. A local causation is also 
found in the various forms of ulcerations of the mucous membrane. 
To the general causes, all conditions which are combined with stasis 
of the venous circulation belong, such as cardiac malformations, goitre, 
the so-called general plethora, pneumonia, and typhus fever, and par- 
ticularly the diseases in which actual disturbances of the capillary 
system of vessels are superinduced, such as scorbutus and morbus 
raaculosus, and diseases of the blood like chlorosis. Finally, vicarious 
hemorrhages occur in girls at the time when menstruation should take 
place. 

Symptoms. — Tlie blood either makes its appearance in drops, as 
stillicidium sanguinis — the ordinary form — or it flows in a continuous 
stream, rhinorrhagia, a rare and exceptional form. As regards the 
quantity of blood lost, we are often unintentionally deceived by the 
relatives, for they forget that the cliild has bled into a vessel contain- 
ing water, and, when they behold the dark red-colored water, im 
agine it to be all blood. Once, in a case of a boy nine years of age, 
who was reported to me as ha\ang daily lost " enormous quantities " 
of blood, I collected what flowed from his nose during thirty-five 
minutes (after which time the hEemorrhage ceased spontaneously), not 
quite one ounce of blood, a quantity that certainly ought to cause no 
great anxiety. 

Cliildren under three or four years very rarely suffer from epis- 
taxis from general causes, but only in consequence of injuries or ul- 
cerations, in which the haemorrhage is never profuse. In older chil- 
dren all the above-mentioned causes are to be taken into consideration. 
In children laboring under febrile diseases, it occasionally happens 
that the blood flows backward into the pharynx and is swallowed, 
when hfematemesis may occur, or black, and more or less bloody 
stools be voided. Usually, the bleeding does not last an hour ; in 
exceptional cases, however, it may be protracted for half a day. 

Its pathological signification is naturally very different, according 
to its severity and etiology. Epistaxis is to be regarded as a favora- 
ble phenomenon in all febrile affections, in venous congestion, and in 
expected menstruation ; as unfavorable, and tending to aggravate the 
condition, in scorbutus and chlorosis. 

Treatment. — From the preceding explanation, it follows that the 
treatment must be exceedingly variable. In scorbutus and chlorosis 
it must be arrested promptly. When occurring in the other states we 
have mentioned, the measures to be adopted will depend upon the 
profuseness of the flow, the frequency of the recurrence of the bleed- 



DISEASES OF THE RESPIRATORY ORGANS. 215 

ing, and the more or less anaemic appearance of the child. The best 
method of arresting the haemorrhage is to introduce a few bits of ice, 
of the size of a pea, into the nares, and then to plug these up with a 
good-sized charpie tampon. The tamponing of the posterior nares 
through the mouth, by the aid of JBellocqite's tube, is very annoying 
to children, and should only be resorted to in extreme cases of scor- 
butus or chlorosis. Where no ice is to be had, it is very advantageous 
to dip the tampon in liq. ferri sesquichlor. The deligation of the 
upper and lower extremities, and the keeping of the arms elevated 
above the head, are popular old remedies. 

That the primary causes always deserve a special consideration is, 
of itself, understood. In order to avoid repetitions, the student is 
referred, concerning their treatment, to their respective sections. 

(2.) CoRYZA — Rhinitis — Catarrh. — By coryza a catarrh of the 
mucous membranes, of one or both nares, is understood, in which af- 
fection the mucous membrane always appears reddened and swollen. 

Symptoms. — The secretion poured out by the mucous membrane at 
first is clear and liquid, but after a few days becomes glairy and 
opaque, until it finally again assumes the properties of the normal 
nasal mucus. Its reaction is always decidedly alkaline, and the 
amount of soda it contains may increase so much as to produce a 
slight corrosive effect upon the upper lip and alse nasi. These local 
signs, reddening and erosions, and the inflammation, are intensely 
aggravated by the constant wiping, which the nursery-maid does not 
always perform in the most tender manner. So long as the catarrh is 
limited to the nasal mucous membrane, it is generally unattended with 
fever, but when it implicates the frontal sinus, or the supramaxillary 
cavities, conditions which can only be ascertained in older children by 
inquiries, it becomes febrile, and is accompanied by severe pains in 
these cavities. When the catarrhal inflammation of the Schneiderian 
membrane extends to the conjunctiva, through the lachrymal canals, 
redness, pain, intolerance of light, in short, conjunctivitis catarrhalis, 
become superadded, and, when finally it passes along through the 
Eustachian tubes into the tympanum, tinnitus aurium, otitis, and 
dyscophosis, come on. In other cases, the catarrhal inflammation 
travels downward into the larynx, causing hoarseness and pain, and 
from thence into the bronchi, where it terminates in bronchitis capil- 
laris in the pulmonary alveoli ; or, lastly, the stomach and intestinal 
canal become involved, when loss of appetite and vomiting of large 
quantities of mucus, or slimy diarrhoea, will be superinduced. 

In older children, these conditions, even when all the enumerated 
complications become superadded, are always devoid of danger ; but, 
in the new-bom child and nursling, a complete occlusion of the still- 



216 DISEASES OF CHILDREN. 

narrow nares, by the tumefaction of the mucous membrane and the 
accumulation of the secretion, rapidly ensues. The usually closed 
mouth must now be constantly open, its cavity becomes dry, and the 
breathing loud and rattling. And if these children now attempt to 
nurse, or take the bottle, they experience great difficulty in breath- 
ing, and are obliged to forsake the breast and food, hence their nu- 
trition rapidly suffers, and emaciation supervenes. The acute form 
generally runs its course in from two to four days, ending in re- 
covery ; in exceptional cases it may merge into the chronic variety ; 
especially is this likely to occur where the acute affection has re- 
curred often, and in reality it is only an aggravated form of the 
latter. Here the Schneiderian membrane is not only reddened, but 
swelled also, and secretes a large quantity of thick and tenacious 
mucus. This is especially the case where the catarrh is engendered 
by the scrofulous or syphilitic cachexia. 

Occlusion of the choanse by thrush-spores also occurs in young 
children who suffer from thrush of the mouth, causing severe dyspnoea. 

Side by side with cataiThal coryza, various cachexias manifest 
themselves in the nasal passages. Thus there is a chronic, scrofu- 
lous, syphilitic coryza, and, in very rare instances, a coryza produced 
by a contagious mucous discharge, in which the secretion is of a 
totally different nature from simple catarrh ; sometimes, even some 
of the bones are destroyed by necrosis. More will be said about 
this condition in connection with the respective dyscrasiae. 

Etiology. — Simple nasal catarrh occurs in a sporadic and epi- 
demic form ; the epidemic occurrence is induced by undue quanti- 
ties of ozone in the air, or by mechanical and chemical adulterations 
of the same ; for example, by dust, in the firing up of a stove unused 
for some time, etc. The liability also to become infectious, by a 
contaminated breath, is not to be ignored. The sporadic and very 
chronic cases, as a rule, are of a cachectic nature. 

Treatment. — In the ordinary catarrhal form, there is no urgent 
indication for interference ; still, it is well to take the precaution to 
keep the children in a uniform temperature, and to avoid sudden 
and extreme cooling of the skin, cold affusions, and cold baths. The 
various abortive treatments that have been tried of late, by injections 
of solutions of zinc, alum, and morphia, in young children who are 
unable to blow them out again, and otherwise liable to swallow 
them, are altogether inadmissible. The only measure worthy of a 
trial is the following preparation : 

IJ. Acid, carbol. puriss., 

Liq, ammon. caustic, aa 3iv. 
Spirit, vini rectificat., 3 iv. 
Aqua destil., 3viij. M. 



DISEASES OF THE RESPIRATORY ORGANS. 217 

A few drops of this are dropped upon a piece of blotting-paper, 
and the patient allowed to inhale it every two hours. Good results 
will also be obtained from foot-baths, and minute doses of opium, 
ajjpropriate to the age of the child. In the treatment of the aggra- 
vated form of the Schneiderian membrane, Weber's nasal douche 
renders excellent service ; this apparatus, however, can only be em- 
ployed in older children, and care should be taken that the injected 
liquor and pus escape readily through the other nostril, otherwise 
they may be forced into the Eustachian tube, and thus set up inflam- 
mation of the tympanum. The nostrils of nurslings that become 
occluded by swelling and secretion must be made permeable by the 
use of olive-oil, introduced by a small brush at least one inch, and 
repeated three or four times daily ; this procedure will be all the 
more successful if they sneeze each time, and thus expel the hardened 
mucous crusts. The cachectic coryza of course does not yield to a 
local treatment, but must be removed by internal antidyscrasiac rem- 
edies. Cod-liver oil is the most effective remedy for the scrofulous 
form, and a mercurial treatment will be required for the syphilitic. 

(3.) Adventitious Growths i]*t the Nose. — Polypi are the only 
morbid growths ; they only occur in older children, and with them 
they are much rarer than in adults. The youngest child in whom I 
twisted off a fibrous polypus was four years old. By polypi we un- 
derstand two kinds of tumors, which differ considerably from each 
other. Soft polypi are cystic gelatinous excrescences upon the 
mucous membrane ; they usually spring from the outer wall of the 
nares, and, on account of their softness, are called cystic or mucous 
polypi. The hard polypi do not spring from the mucous membrane, 
but from the submucous tissue, or from the perichondrium. They 
consist of connective tissue, are of a rosy-red color, and, on account of 
their hardness, have been called fibrous or sarcomatous polypi. Both 
kinds are pediculated, and enlarge themselves into oblong tumors, 
corresponding to the shape of the nares. The fibrous polypi may at- 
tain to so considerable a size, especially backward, as to hang down 
into the pharynx, and embarrass deglutition and even respiration. 

Etiology, — According to the text-books, polypi originate from 
chronic catarrh. This theory rests upon a feeble foundation, and 
has many exceptions. Their rare occurrence in children also speaks 
against it, for in these especially the mucous secretion is much 
greater, even in the physiological state, than in adults. In the few 
instances that I have had the opportunity of observing in children, 
no chronic catarrh preceded them, and no peculiar etiological reason 
whatever could be discovered. 

Symptoms. — So long as the polypi are small, and the nares not 
blocked up, they seem to give rise to but few or no embarrassments. 



218 DISEASES OF CHILDREN. 

But when impermeability of the nasal passages has been produced, 
then the patients lose the sense of smell, the voice becomes snuffling, 
the mouth is constantly kept open, giving them a silly appearance, 
and they are continually but uselessly seeking to free the nasal 
passage by blowing the nose. Now and then one of these cystic 
polypi, through the violent snuffling and pressure, will burst, the 
contents be discharged, and the air once more pass freely through 
the nares. But, as cystic polypi usually exist in numbers, the 
smaller ones rapidly follow in growth, occlude the passage anew, 
and the old condition is reproduced. Firm sarcomatous polypi are 
also capable of blocking up the lachrymal canal and the Eustachian 
tube, and thus produce stillicidiura lachrymarum and hardness of 
hearing. In cystic polypi this is not observed. In both forms, a 
mucous or purulent coryza, and even ulceration of the mucous mem- 
brane, may take place, as a result of which small haemorrhages also 
occur. The diagnosis is very easy ; ordinarily the polypi reach the 
margin of the nares, or even pi'otrude. When this is not the case, 
the impermeability of the cavity in question may be readily ascer- 
tained by compressing the opposite one, and causing the patient to 
blow his nose. From the presence of foreign substances, polypi are 
distinguished by the slowness of their growth, by slight painf ulness, 
and their chronic course. Cystic polypi very frequently return ; 
fibrous polypi, when thoroughly removed, generally do not. 

Treatment. — Internal remedies, as well as the local application of 
astringents, have proved to be totally useless ; the only effectual 
treatment consists in twisting off and eradicating the polypus, care 
being taken to grasp it close to its origin, from the mucous mem- 
brane. A long, slender, serrated forceps is the best instrument for 
this purpose. 

For the removal of fibrous polypi with broad pedicles, Mlddel- 
dorpfs galvano-caustic is very well adapted. The haemorrhage 
produced by the evulsion of the polypus is readily arrested by injec- 
tions of cold water, and the introducing of pieces of ice. After the 
removal of cystic polypi, dossils of charpie, smeared with red-pre- 
cipitate ointment, should be introduced into the nares for several 
weeks, to prevent its return. 

(4.) Foreign Bodies in the Nose. — Children from two to eight 
years of age very frequently introduce extraneous substances into 
the nose. The most common are cherry-pits, small round pebbles, 
glass beads, peas, beans, and paper balls. In addition, insects, such 
as flies and bugs, gain an entrance into the nose while children are 
asleep, or a round-worm strays (probably during a fit of vomiting) 
into the nose. Generally, as soon as a child introduces a foreign 
body into the nose, it straightway tries to remove it by boring with 



DISEASES OF THE RESPIRATORY ORGANS. 219 

the finger, and thereby only pushes it into the choanse, where it 
finally becomes lodged. The irritation that is produced by these 
foreign bodies varies according to their composition. If some part 
of the surface is rough, painful swelling and coryza will soon be in- 
duced ; beans and peas produce the greatest amount of irritation, 
they soon swell up in the moist, warm cavity, and may even begin 
to sprout there. A remarkable case of this kind is recorded by 
Boyer, in which a pea germinated in the nose of a child and bore 
ten or twelve roots, one of which grew to three and a quarter inches 
in length. 

The nose becomes very painful, and, without chloroform, no 
thorough examination can be made. The termination is most favor- 
able in those instances where paper balls have been introduced into 
the nose ; they soon soften and are discharged piecemeal. How- 
ever, cases are also said to have occurred in which the foreign bodies 
produced severe irritation, delirium, meningitis, and death. The 
condition called rhinolites, in which successive deposits of inorganic 
salts take place around the foreign body, sometimes met with in the 
adult, is, so far as I know, unknown in the Pasdiatrica. 

Treatment. — A painless and yet in many instances a successful 
remedy is, the act of sneezing, which may be excited by a pinch of 
snuff, used in the sound nostril. Even when the extraneous body 
is not entirely expelled, it will nevertheless always be found to have 
been propelled forward, and somewhat loosened. As soon as it be- 
comes visible, it may be extracted with a very fine dentated forceps 
or DavieVs scoop. Soft bodies may also be crushed with a strong 
dentated forceps, when the single pieces will soon be expelled. 
The attempts at extraction should never be persevered in too long, 
because very severe swelling of the mucous membrane will thereby 
be produced. They may be repeated again in a few days. Under 
no circumstances is the nose to be split open hastily, as recom- 
mended by JDiffenbaoh / the operation should be defei'red until 
critical cerebral symptoms render it necessary, which, on the whole, 
very rarely occur. 

S.— LARYNX AND TRACHEA. 

(1.) Pseudo-croup {Laryngitis Catarrhalis). — When an adult 
contracts a catarrh of the larynx, he becomes hoarse, has a tickling 
and itching sensation in the larynx, and along with that coughs, but 
dyspnoea and fits of choking do not occur, as a rule. If a child, on the 
contrary, falls sick with a simple catarrhal swelling of the laryngeal 
mucous membrane, violent disturbances of the respiration immediately 
set in, having their foundation in the narrowness of the chink of the 
infantile glottis. There seems to be a different relation in the larynx of 



220 DISEASES OF CHILDREN 

the child, between the swelling of the mucous membrane and width 
of the chink of the glottis, from that which exists in the adult. While 
the glottis of the latter still tolerates a certain degree of catarrhal in- 
filtration, without inducing any very severe dyspnoea, it very often 
happens that children, who are scarcely noticeably hoarse, are sudden- 
ly attacked by fits of suffocation, and for the time present a deceptive 
similarity to genuine fibrinous croup. 

Symptoms. — There is a very simple catarrh of the nose or bronchi, 
or of both at the same time ; the patients are comfortable the whole 
day through, and eat with the customary appetite, and, aside from a few 
sneezes and coughs, are in perfect physiological condition. They fall 
asleep at the proper time, cough perhaps a little during the sleep, or 
snore in an unusual manner, but suddenly wake up with a well-marked 
attack of croup. Croupy cough, hoarseness, croupous respiration, and 
very violent choking-fits, immediately come on, and now no person is 
able to distinguish this affection from genuine croup. The same anxiety 
and oppression also supervene ; the child rises to a sitting posture, 
the face becomes red, and the pulse considerably accelerated. These 
sjTnptoms last for one, or at the longest two hours, and then begin to 
subside ; the breathing and the voice become almost normal, the child 
Hes down again, may call for drink, and then fall asleep, during which 
a general perspiration breaks out. The physician, Avho usually arrives 
at the house about this time, finds a perfectly healthy, sleeping child, 
who wakes up very indignant at again being disturbed in its night's 
rest. Two or more attacks seldom take place in one night, but 
they generally recur in the following nights, and sometimes even 
after they have been absent for many days or even weeks. Slight 
hoarseness, a barking cough, and loud snoring during sleep, gen- 
erally remain after the attack ; the temperature of the skin on the 
hands and forehead may, it is true, be slightly elevated, but actual 
fever, with general malaise and great depression, does not occur. Chil- 
dren thus attacked desire to leave the bed and partake of their meal, 
although not with a full appetite. Strange to say, no violent attacks 
ever occur in the da\-time ; a fact due perhaps to the greater sensibil- 
ity of the larynx to the masses of mucus accumulating within it during 
sleep. In the daytime, as soon as this accumulated mucus is of any 
amount, it excites cough-paroxysms, and is finally coughed out from 
the larynx into the pharynx, while at night it remains there for a 
longer time, and then induces violent reflex phenomena. 

The entire duration of the aflBiction is from three to eight days. The 
usual, indeed almost invariable, termination is in recovery ; but cases 
also occur in which children for many days display distinct catarrhal 



DISEASES OF THE RESPIRATORY ORGANS. 221 

laryngitis, but finally, under aggravation of the general disease, fall 
into genuine croup, whicli generally terminates in death. At the au- 
topsy, membranes are not commonly found in these cases, nothing 
more than a marked swelling and reddening of the laryngeal mu- 
cous membrane, and upon it, as well as upon the tracheal and 
upon the pharyngeal mucous membrane, a thick coating of tenacious 
mucus. 

Pseudo-croup is very much disposed to relapses, as is often learned 
from the statements of adults, who claim to have had the disease six 
and eight times in 'their youth. It most frequently attacks children 
in whom the eruption of the last molares is in progress, but does not, 
however, spare older ones ; while in small children, who still labor under 
the effects of cutting the incisor teeth, the spasmodic form of laryngeal 
affection, without any catarrh, is the most frequent variety. More- 
over, there are also transitory forms in which it is very difficult 
to decide whether we have to deal with a simple spasm of the 
glottis or pseudo-croup. Only the hoarseness of the voice and the 
croup-tone of the cough in the intervals allow the diagnosis for this 
or that form to be established with certainty, for these symptoms 
never occur in pure spasms of the glottis. Pseudo-croup is also dis- 
tinguished from genuine croup by its intermittent character. Al- 
though in the former the voice in the daytime is hoarse, and the 
cough affected vnth a croupy clang, still the fever and the general 
affection will never awaken any special anxiety ; the children get up, 
are lively, amuse themselves with their playthings, and even partake 
of some nutriments. But from all this the case is totally the reverse 
in genuine croup, and the laryngeal symptoms are always much more 
pronounced. 

Treatment. — Pseudo-croup should never be regarded slightingly 
even in its mildest form ; for very gradual transitions into the genmne 
croup happen, and, after the fatal termination of which, we may, when 
too late, regret having carelessly treated the first hoarseness. Chil- 
dren thus affected are to be kept in a perfectly uniform temperature ; 
the neck should be wrapped up, and they should be confined to a 
milk diet and plain soups. Moist compresses to the neck, when prop- 
erly applied, act very favorably. The compress should be no wider 
than a narrow cravat, covered by a piece of gutta-percha, and these 
confined around the neck by a second dry cloth in such a manner that 
the water will not run down upon the body, and cause a too rapid 
evaporation and partial cooling of the neck, by which the hoarseness 
generally becomes aggravated. This danger on the one hand, and 
the conviction that the wet cravat is not always absolutely necessary, 



222 DISEASES OF CHILDREN. 

have induced me to discard it altogether where a special and expe- 
rienced nurse does not undertake the care of the child. Internally, I 
generally give kali carb. (3ss — 3] to Avater | iv), and allow the pa- 
tients to drink as much as possible, because experience has proven 
that, by promoting diuresis and diajDhoresis, a mitigation of the ca- 
tarrhal secretion of the respiratory mucous membrane is produced. 
It will seldom be necessary to resort to emetics. 

(2.) Neukosis op the Larynx. — Motor disturbances of the 
laryngeal muscles frequently and almost exclusively occur in childhood. 
Both forms, the spasm and paralysis, are observed, but the former is 
much more frequent than the latter. It must be premised that, as a 
rule, all those laryngeal affections must be excluded in which any 
symptom of material lesions of the mucous membrane can be de- 
tected; for, since the muscles of the lar^mx must by such lesion 
become altered, a change of the voice follows, as well as a change in 
the manner of breathing, and in the cough. These exclusions hav- 
ing been disposed of, the neuroses remain. In slighter deviations 
from the normal construction, w^iich, in the cadaver, presents a path- 
ologically altered mucous membrane, it is often difficult to decide 
whether death resulted from a pure neurosis, or from a swelling of 
the mucous membrane, or an oedema of the glottis. 

(a,) Sjyasmiis GlotticUs. — That the glottis may become spasmodi- 
cally contracted is no longer any subject of doubt. This may be 
demonstrated experimentally by vivisections, and is anatomically con- 
firmed by the insertions of the muscles of the larynx. Tliese muscles 
are supplied by the recurrent laryngeal nerve, and are (1), the thyro- 
arytaenoidei ; (3), the cricoarji;aenoidei laterales ; and (3), the arytae- 
noideus transversus. 

An acute and a chronic form may be distinguished. There are 
spasms of the glottis in which death ensues, after the first few par- 
oxysms, by choking or sufibcation, and others again which last for 
months, and may relapse after very long pauses. The Avriters of the 
preceding and of the present century record no precise reports con- 
cerning this condition, but differ remarkably from each other in their 
views upon it, and consequently have invented a number of names, 
most of which are based upon etiological views, causing the greatest 
confusion in the minds of those physicians who do not rely upon their 
owTi investigations. Thus there was an asthma acutum et chronicum 
]\Iillari, the symptoms of which, however, are more applicable to our 
own pseudo-croup than to a pure spasmus glottidis — an asthma thy- 
mico-cyanoticum — a suffocatio stridula — an angina stridula — apnoea 
infantum — catalepsis pulmonum (Hufeland) — a laryngismus stridulus 
-— phreno-glottismus — larjTigo-spasmus infantilis — tetanus apnoicus 



DISEASES OF THE RESPIRATORY ORGANS. 223 

iufantum — and finally even a cerebral croup, by which the English, 
especially Clark, understood a species of croup, at the autopsy of 
which the larynx was found unaffected, and which, of course, was al- 
ways ascribed to a cerebral disease that was not demonstrable. 

Symptoms. — The following morbid picture may be delineated in 
general outlines. Usually very healthy, robust children are seized 
during the process of dentition with a suffocative attack. All at once 
the face becomes strongly injected, the head is thrown backward, the 
mouth is slightly open, or makes snapping movements ; the extremi- 
ties are stiff, or hang down powerless ; the child also plucks at its 
neck, as if it would tear away the cause of its strangulation. Finally, 
after a most tormenting struggle of a half to one minute, a few short, 
abrupt whistling inspirations follow, with which no expirations alter- 
nate, and then the whole fit is either at an end, and the normal respira- 
tion inducted again by a prolonged whistling expiration, or another 
suffocative attack, with totally arrested respiration, begins. This entire 
phenomenon may recur several times in succession, so that the child 
does not return to normal or much improved respiration for several 
minutes. The paroxysms occur as often in the daytime as in the 
night, and may return forty times in the twenty-four hours ; they 
are especially induced by deep inspirations. If the disease has ex- 
isted for a certain time, general convulsions will become superadded 
to the spasm of the glottis — a condition which has been described by 
some authors as the second stadium. 

If we are to analyze the individual symptoms more accurately, it 
will be necessary to classify them first into two groups: (1), as to 
the symptoms during the attack, and (2), the symptoms in the inter- 
vals. 

(ad 1.) The tone which accompanies the first inspiration after the 
suffocating fit, and at the beginning of the cataleptiform state, popu- 
larly called " Ausbleiben " in German, is always very characteristic. 
It is a crowing, whistling cry (the crowing inspiration of the English), 
and is tolerably accurately imitated by executing a sipping inspira- 
tion through the almost-closed chink of the glottis, while at the same 
time attempting to utter the vowel i. Sometimes this cataleptic state is 
also ushered in by a few of these inspirations, but, in most instances, 
the children have not the time for that, and, as if strangled, gasp 
voicelessly for air, along with which they become livid, and throw 
the head backward, in order to dilate the chink of the glottis as much 
as possible. Immediately after the attack, the expirations are super- 
ficial and apprehensive, but soon become perfectly normal, and free 
from the whistling noise heard in croupy breathing. 

Tlie superadd! ti on of general convulsions to spasmus glottidu 



224 DISEASES OF CHILDREN. 

(second stadium), as relates to prognosis, is very important. The 
thumbs are now drawn in toward the pahns, the forearms strongly 
pronated, and all the adductors of the upper extremities affected with 
spasmodic contractions. The feet, on the contrary, are rigidly ex- 
tended, the great toes abducted and drawn upward. The muscles of 
the face are thrown into convulsive action, and opisthotonos may ap- 
pear. The temperature of the extremities is much more likely to be 
diminished than increased. These general convulsions plainly depend 
upon those of the glottis, for they appear and disappear with them. 

During the 2Daroxysm,the face, of course, becomes flushed and even 
cyanotic. The congested eyeballs protrude from their cavities, the 
tongue becomes bluish-red, and the veins of the neck distended, and 
the face is stamped with the expression of the utmost anxiety. 
During the attack itself it is very difficult to feel the pulse, or to dis- 
tinguish by auscultation the sounds of the heart. Indeed, such an 
examination, at a moment of so great danger to life, is not only use- 
less, but improper and cruel, and should not be practised at such ex- 
pense of most precious time. Several minutes after the paroxysm 
the pulse is still distinctly felt to be unrhythmical and irregular. The 
ffeces, and less frequently the urine, are passed involuntarilj'- during 
the paroxysm. 

(ad 2.) The symptoms during the intervals are diflPerent, according 
to the severity and the duration of the paroxysms. Most children, 
during the interval, are tired and petulant, but in the mild cases ap- 
petite and sleep are enjoyed. In those instances where the spasms 
are intense and frequently repeated, the child loses its appetite, be- 
comes emaciated, and suffers more or less fever. 

Duration, Course, and Prognosis. — The duration of this disease 
cannot be fixed at any given time. Sometimes even the very first at- 
tack terminates in death, and a seemingly perfectly healthy child may 
be carried off in a few seconds. Others may suffer for months, pe- 
riodically, as often as a tooth breaks through, from a crowing, whist- 
ling inspiration, not, however, from total closure of the glottis, and 
its extreme symptoms, as the normal respirations recur after a few 
seconds. In most cases, the disease runs through a certain circuit, in 
which an aggravation, a climax, and a diminution, can be recognized. 
At first the attacks are rare, recuri'ing every eight or fourteen days, 
but in the process of time they become more frequent, finally occur 
several times daily, and increase in intensity. Before this climax has 
been reached, six to eight weeks generally pass away. The chil- 
dren either perish in a fit, or, when this acme has lasted for from eight 
to fourteen days, are attacked by fever and become emaciated. A lobu- 
lar pneumonia or a profuse intestinal catarrh may come on, and result 



DISEASES OF THE KESPIRATORY ORGANS. • 225 

in death. Recovery, unfortunately, happens very seldom when the 
disease has once passed beyond a certain grade of severity. In the 
favorable case, the paroxysms remit in frequency and finally cease 
altogether. But the child remains very backvs^ard in its development, 
is always pale, rachitic, and predisposed to relapses, which, however, 
seldom terminate unfavorably. Out of fifteen cases of which I have 
kept a record, eight died. Rilliet and JBarthez, out of nine cases, and 
Serard out of seven, observed in each only one single instance of re- 
covery. It may be safely assumed that this relative mortaUty had 
turned out rather too unfavorable, since only the serious cases under 
the care and watchful eye of the physician are taken into account ; 
and the milder forms, wliich gave the physician but little trouble, 
and caused the parents no great anxiety, are probably not men- 
tioned. 

The prognosis depends upon the frequency and intensity of the 
attacks, upon the complication, and upon the comparative development 
of the child. Children at the breast recover oftenest ; thin, emaciated 
children, and those inclined to atrophy, very rarely. The more de- 
veloped and extensive the craniotabes is, the more unfavorable is the 
prognosis ; the connection between it and spasm of the glottis will 
be more thoroughly discussed in the following section. 

Etiology. — We have to discriminate between the causes which 
give rise to, or favor the single paroxysms, and the general exciting 
causes which are particularly predisposing to the disease. 

To the first belongs fright. A loud, suddenly-produced noise suf- 
fices to induce a spasm of the glottis. It may also be produced by 
depressing the tongue in the examination of the mouth, by the acts 
of deglutition, by coughing, and by crying. But the closure of the 
glottis brought about by crjdng should be carefully distinguished from 
that cataleptic state into which very choleric and somewhat older 
children, from two to four years of age, are volicntarUy able to work 
themselves. There are very man}'-, chiefly badly-brought-up, spoiled 
children, who at the slightest provocation throw themselves into vio- 
lent paroxysms of crying, and exert themselves so forcibly tliut they 
are for a moment unable to draw their breath, and for an instant be- 
come li-sdd or even bluish-red in the face, and then begin their cry 
anew with a whistling, prolonged inspiration. This kind of voluntary 
unconsciousness is by no means dangerous, and there is no reason at 
all why the Avill of such children should be humored in order to avoid 
this condition. The most rapid psychological method of treating it 
is, to dash a glassful of cold water at once into the face. 

When the disease reaches its climax, it will require no active 
cause to induce a paroxysm. Tlien the attacks come on during the 



226 ■ DISEASES OF CHILDREN. 

calmest sleep, undei the quietest circtimstances, and at any time, with- 
out the least exciting provocation. 

By analyzing the general causes^ very peculiar phenomena are elu- 
cidated. First of all, as regards the sex, spasmus glottidis attacks 
boys much oftener than girls ; a fact almost all authors admit. 
Out of my fifteen cases, eleven were boys, so that it seems as if the 
larynx of male children begins even in the very earliest youth to dis- 
tinguish itself in form, or at least in physiological activity', from that 
of female children. 

The age at which the disease occurs fluctuates between one half 
and three years ; that is to say, it makes its appearance with the erup- 
tion of the first tooth, and disappears with that of the last. It occurs 
much oftener with the cutting of the incisor teeth, in the first half year 
of life, than with that of the canine and molar teeth. The thought 
constantly suggests itself, whether a direct extension of the reddening 
and swelling of the mucous membrane, as a result of dentition, to 
the larynx, might not be assumed. In that event, however, spasm 
of the glottis would be most sure to occur where the local troubles 
of dentition are most perfectly pronounced. But this, according to 
my obsen^ation, is by no means the case. In most of these children 
I found the mouth not particularly reddened, and without profuse 
secretion. 

The hereditary character of spasm of the glottis is interesting. 
There are families in which all the children suffer more or less from it, 
and Poicell even relates an instance where, out of thirteen children, 
brought up by the same parents, only one escaped the disease. The 
mothers of the children whom I have treated for this disease were all 
of a tolerably excitable nature, and often complicated the child's 
disease by indulging in their habitual hysterical outbursts. 

The connection between craniotabes and spasmus glottidis (teta- 
nus apnoicus) has been satisfactorily demonstrated by JSlsasser, the 
discoverer of the soft occiput. Not the softness and depressibility of 
the occiput jyer se, but their effects, should be regarded as the exciting 
causes, as the meninges may thereby degenerate into an abnormally- 
congested condition ; true plastic exudations are not generally found 
in children who died from this disease. The discovery of the relation 
between these tAvo diseases by Elsasser was subsequently fully con- 
firmed by many authors, especially Lederer, and cases have even been 
recorded in which spasm of the glottis could be voluntarily induced 
by pressure on the softened places of the rachitic occiput. Without 
doubting altogether tliis mechanical cause, it can, nevertheless, only be 
regarded as an exceptional one ; for, if it had a general applicability, 
then the paroxysms ought to come on oftenest during sleep, when 



DISEASES OF THE EESPIRATORY ORGANS. 227 

children lie with the occiput pressing the pillow, than in the waking 
state, when they are mostly carried about upright. But exactly the 
contrary is the case. The hyperasmes of the brain, and of its mem- 
branes, upon which Elsasser lays a particular amount of stress, are 
much more probably the effect than the cause of the disease, and when, 
ex juvantibus et nocentihus, a conclusion might be made upon the 
nature of a disease, then they stand in no causal connection at all 
with the spasms, because otherwise these should be cured or palliated 
by local abstraction of blood, and by a derivative action upon the bow- 
els, a result well known to be impossible of achievement by these 
means. We must therefore limit ourselves to admitting the remark- 
ably frequent concomitance of spasmus glottidis with craniotabes, as 
irrefutable facts, but reqxiire further physiological and anatomo-patho- 
logical investigations, for the conclusive proof as to cause and effect. 

Disturbances of the digestion may likewise produce spasms of the 
glottis, as may be readily inferred from the fact that a sensible regu- 
lation of the diet, and abstaining from nutriments difficult to be digest- 
ed, bring about a speedy improvement ; while all treatment is fruitless 
so long as the digestion is attended by flatulence or diarrhoea, or other 
disorder. Children at the breast are extremely rarely affected by this 
disease ; and, of the artificially-fed children, mainly those who do not 
properly digest the immoderate quantities of food allowed them suffer. 
That the children of affluent parents are totally spared by this afflic- 
tion, as Rilliet has observed, in Genf, cannot be maintained by us in 
Munich. The children of poor people do, indeed, oftener fall sick 
with it, but it should not be forgotten that in all cities there are more 
of these than of rich. 

Finally, JK^opp, and, after him, a great number of physicians, as- 
sumed the thymus, gland to be a cause, and, indeed, the only one, so 
that the description of " Asthma-thymicum Koppii " is even used at 
the present day by some of the older physicians. But pathological 
anatomy has overthrown this theory. A large thymus gland has often 
been found in the cadavers of children who have died from totally 
different diseases, and never suffered from spasm of the glottis ; and, 
conversely, in many cases where this was the cause of death, a normal, 
and even an atrophied thymus was observed. Hence, it seems that 
we must discard asthma-thymicum altogether, as a denomination of a 
disease. 

Pathological Anatomy. — So far as the larynx itself is concerned, 
the morbid appearance is invariably of a negative character, and thus 
the spasmodic nature of the disease is also confirmed by the joos^ 
mortem examination. The rest of the appearances are not constant, 
and consequently not characteristic. Rachitis is most frequently 



22S DISEASES OF CHILDREN. 

found and most extensively marked upon the occiput, and next in fre- 
quency on tlae ribs. The thymus gland is sometimes large, some- 
times small, and at times undergoing complete absorption. In the 
intestines, solitary glandular indurations are sometimes found ; in the 
bronchi, catarrh, and, in the lungs, tuberculosis may also have ap- 
peared. The bronchial glands, in particular, are degenerated into 
large, cheesy tubercles. Hypertrophy and an injected state of the 
meninges are frequent morbid appearances. By some investigators 
the pneumogastric nerves have been found hardened, by others again 
soft. 

Treatment. — (a.) Prophylaxis. — When one or several children of 
a family have already perished by spasm of the glottis, the parents 
are naturally in a state of constant fear that they may also lose 
those subsequently attacked, and therefore declare themselves ready for 
any sacrifice by which this calamity might possibly be averted. In 
this respect the country air is particularly recommended, but it must 
be remarked that it is only usefxil during the few summer months, 
when children may actually be taken out into the free air, and 
that the mothers, in such cases, are very averse to parting with their 
family physician ; and, lastly, residence in the country by no means 
supplies a positive guarantee against the appearance of the spasms. 
I myself have twice been taken to the country to see children with 
spasm of the glottis, who were born there, and had never yet been in 
the city. Hence it seems more advantageous to leave the children in 
the house of the parents, and under the care of the regular family 
physician, where they can enjoy fresh air several hours daily in some 
neighboring park. Such children should be kept as long as possible 
at the mother's breast, at least till they have cut the first six in- 
cisors. The supervention of the occipital rachitis is sought to be 
averted by zealous ventilation of the room, by keeping the head cool, 
bathing it with water, and by aromatic baths. AU sorts of di- 
gestive disturbances should be remedied as quickly as possible by 
small doses of alkaline carbonates, to which a little rhubarb may be 
added, Avhen constipation is present. 

(b.) Treatment of the Attach. — One minute is but a short time for 
the selection and application of a remedy, and it is altogether incom- 
prehensible how some physicians would have us treat the attach with 
sinapisms, emetics, clysters of various kinds, and with warm baths, 
the preparation of which certainly requires a much longer time. 
The first thing to be done is to raise up the child, and throw 
the head backward, so as to give the larynx the most favorable atti- 
tude, and to remove all the tight clothes from the chest as quickly as 
possible. In the instances where I happened to be present at the 



DISEASES OF THE RESPIRATORY ORGANS. 229 

paroxysms, I introduced the index-finger into the mouth, carried it to 
the posterior pharyngeal wall, elevated the epiglottis, and then touched 
the chordae vocales, by which marked acts of choking were instantly 
induced, and then the well-known whistling inspiration followed. 
I^ay people, of course, are unable to execute these manoeuvres, and I 
therefore content myself by showing them how retchings may in- 
variably be induced by pressure upon the root of the tongue. The 
shock produced by inducing this act of retching is the only harmless 
remedy which will cut short the paroxysm. From affusions with cold 
water, and from the forcible to-and-fro swinging in the air, very much 
in vogue wdth the nurses, I have seen no decided effects ; chloroform is 
very urgently recommended by many physicians, especially by Cox 
and Sinage. It seems to me, however, to be too dangerous an agent 
to be left to the use of the lay attendant. Tracheotomy, which has 
been suggested as a dernier ressort, with which to save the life of the 
child, can never be performed, on account of want of time. 

(c.) Causal Treatment. — Such a list of remedies, for the subjuga- 
tion of the developed spasm of the glottis, has been recommended, that 
the very number alone must excite mistrust. Those still in greatest 
favor are : oxide of zinc in grs. ii — x pro die, argent, nit.., gr. -J — \ 
pro die, ammoniate of copper., asafoetida, tr. moschata., aq. amyg- 
dal. amar., belladonna, hyoscyamus., opium, cannabis indica, five 
drops every hour, and small doses of calomel. All of these reme- 
dies are uncertain, and have no specific effects whatever, for the ma- 
jority of children perish notwithstanding the kind of treatment and 
remedies used. There is but one remedy by which the rachitis can 
be positively brought to a stand-still, and that is the raw, strongly- 
rancid cod-liver oil, and if the frequent concomitance of rachitis of the 
skull with spasm of the glottis is not lost sight of, then this agent has 
yet the greatest claim to a rational method of treatment. In fact, I 
have already seen three children recover by the use of ol. jecoris. It is 
to be regretted that it is very often not tolerated by the stomach, pro- 
ducing gastricismus and vomiting, on account of which, of course, it 
has to be discontinued.* 

Scarification of the gums, which the English make various uses 
of, has found but little favor with us. In one child, in whom the two 
bicuspids were very nearly through, I performed it very energetically, 
but without the least effect. The paroxysms occurred oftener and 
oftener, constantly grew more and more violent, and the child suc- 
cumbed, although the swollen gums had been completely removed, 
and the sharp edges of the teeth were plainly visible. 

* [I have obtained excellent results from camphor and sodas bromat., given in an 
emulsion, one to two grains of the former to six to ten grains of the latter, according 
to the age of the child. The spasms were undoubtedly controlled, and occurred less 
often. At the same time I do not omit the use of the cod-liver oil.] 
16 



230 DISEASES OF CHILDREN. 

Combined with tlie internal administration of ol. jecoris, I have 
lately kept two children constantly in a mild camphor-atmosphere, 
by suspending from their necks bits of camphor loosely tied up in a 
rag. Both children recovered; whether this camphor-atmosphere 
contributed any thing thereto, more extensive trials may deter- 
mine. 

(b.) Paralysis Glottidis. — Paralysis of the glottis is a rare affec- 
tion. Tliis may appear remarkable, since tumors grow so frequently 
about the neck, and are liable to exercise pressure upon the vagus 
and recurrent laryngeal nerves, and thus produce paralysis of the 
laryngeal muscles. In vivisections after division of the recurrent 
laryngeal nerves, the glottis is seen neither to dilate during inspira- 
tion nor to contract during expiration ; but in a very deep inspiration 
it mechanically becomes narrowed or closed, as the strong current of 
air gives to the chordas vocales the form of two segments of a wheel, 
and their borders are thereby made to approximate, or even to touch 
each other, and thus be converted into valves. Paralysis of the 
glottis, resiilting from disease of the central nervous system, is ob- 
served in most of the dying, and in very rare instances may also be 
caused by tumors, by large tubercles, or by carcinoma, existing 
at the base of the brain, a long time before death. Peripheral 
paralysis of the glottis originates through pressure upon the cervical 
portion of the pneumogastric, or upon the recurrent laryngeal nerve, 
wliich alone, according to the united investigations of Vblkmann, 
Z/onget, etc., may give rise to dilatation, as well as to closure of 
the glottis. The pressure, as a rule, is caused by scrofulous en- 
largement of the lymphatic glands, lying in the course of the vagus, 
in which, at the autopsy, this and the recurrent nerves are found em- 
bedded and flattened. This fact furnishes a means of explaining the 
violent paroxysms of dyspnoea that sometimes occur in scrofulous chil- 
dren, in whom the external glandular swellings are often so insignifi- 
cant that a dyspnoea, induced by their pressure directly, is altogether 
out of the question. 

Symptoms. — The principal symptom is an uninterrujDted, labored, 
rattling respiration, which, at every deep inspiration induced by 
crying, laughing, and strong exertions, terminates in a paroxysm of 
cough. 

The respiratory sound is as loud as in croup, but is distinguished 
from croupy breathing by the less shrill and more rattling tone, and, 
in addition, by the ordinarily very slight dyspnoea, which, however, 
during the cough-paroxysms becomes more marked, and is often 
aggravated into an orthopnoea. This condition is always chronic, and, 
when no other afllictions are accidentally present, not attended bv 



DISEASES OF THE RESPIRATORY ORGANS. £31 

fever. The voice here is rough, hoarse, and even complete aphonia 
may exist. 

The duration of this affection cannot be foretold. On one occasion 
I saw it disappear spontaneously, although the glandiilar swelling 
visibly increased in size. It is presumed that a softening or absorp- 
tion of the deeper portions of the gland took place, and thus re- 
lieved the pressure. Generally, the prognosis is unfavorable, a 
diffused bronchitis soon supervenes, and not unfrequently pulmonary 
tuberculosis, which in a short time carry off the patient. 

Treatment. — As scrofula is almost always at the bottom of this 
affection, an antiscrofulous treatment will, therefore, be absolutely 
indicated. Cod-liver oil is decidedly the best remedy for it ; locally, 
painting with iodine, repeated two or three times every week, most 
rapidly effects a diminution of the glands. If, in this manner, we do 
not succeed in removing or at least in mitigating the evil in from eight 
to fourteen days, it will be absolutely necessary to extirpate the affected 
glands. The effects which the hypertrophied glands produce show 
conclusively that they extend deeply down, and this operation should, 
therefore, only be undertaken by a skilful operator, well versed in the 
anatomy of the parts. 

Q,.— THYROID GLAND. 

If we exclude the extraordinarily rare thyroiditis inflammatoria, 
and traumatica, which may occur as the effects of external injuries, such 
as from throttling, contusion, etc., there will only remain for consider- 
ation the various kinds of hypertrophy of the thyroid gland. 

Struma. — By struma we understand all kinds of enlargement of 
the thyroid gland. Sometimes the increase in size is only tran- 
sient ; generally, however, it is permanent, and constantly progresses. 
Either the whole gland hypertrophies, or only a single lobe or a 
small section of a lobe, and the symptoms of compression vary ac- 
cording to the direction in which the enlargement progresses. 
When the gland enlarges outwardly and anteriorly, the integument 
covering it will become gradually distended, and, with the exception 
of the unsightly disfigurement, no further disturbance of the functions 
of the adjacent organs will ensue. But if it becomes enlarged back- 
wardly and laterally, the sterno-cleido-mastoidei muscle and the large 
vessels and nerves of the neck will be displaced, and manifold disturb- 
ances of the circulation and innervation supervene. With these, seri- 
ous embarrassments of deglutition and of respiration become asso- 
ciated. When, for example, and fortunately very rarely, it happens 
that the strumous gland surrounds the oesophagus and trachea like a 



232 DISEASES OF CHILDREN. 

ring, the symptoms assume a very serious aspect ; and when the lower 
border of the gland enlarges in length, growing downward beneath 
the manubrium sterni, it hypertrophies in every direction. 

The enlargement of the gland takes place in two ways. Either 
the granules or cells of the normal gland become developed in greater 
numbers, and thus produce a perfectly normal glandular substance, but 
hypertrophied in volume (struma lymphatica), or a few thyroideal 
granules become enlarged into extensive cysts, which even in children 
a few years old may attain to a diameter of one inch and more (struma 
cystica). The contents of these cysts are a semi-consistent, gluey, yel- 
low, or brown liquid, for which the name of colloid has been in- 
vented. In goitre of children the walls of the cyst are invariably 
attenuated and soft, while in older individuals they are well known to 
be markedly thickened, and have even been found to have under- 
gone ossification. The cystic goitre has a nodular and uneven feel ; 
large cj^sts fluctuate distinctly ; lymphatic goitres never disj^lay 
any globular distention, and have a uniform consistence in every di- 
rection. 

Infants occasionally come into the world with congenital lymphatic 
strvima, they are liable to be semi-asphyxiated, and are only with 
the greatest difficulty brought to life, and, even after that, they breathe 
loud and laboriously. This goitre of the new-bom 'child disappears 
spontaneously in a remarkable manner after several weeks. Usually, 
however, older children, girls particularly often, are afi'ected by it after 
commencing the second dentition, and here the lymphatic struma is 
as frequently met with as the cystic. In children the above-mentioned 
serious symptoms from displacement of and pressure upon the organs 
of the neck, and of compression of the trachea beneath the sternum, 
are, on the whole, extremely rare ; usually medical assistance is only 
sought on account of the unsightly appearance. 

Treatment. — Surgical interference, on account of the dangers at- 
tending upon the extirpation of goitres, and even upon simple punc- 
tures and injection of the cysts, is only admissible when the symptoms 
are of the most urgent kind ; no operative procedure should be under- 
taken solely on account of the disfigurement. Lymphatic struma 
uniformly disappears under the external use of iodine repeated six to 
twelve times, at from three to six days' intervals. Cystic goitre does 
not disappear under this treatment, but becomes visibly smaller, or at 
any rate does not grow larger, so that, with the increasing size of the 
body, the deformity becomes less striking. Tincture of iodine acts 
remarkably quick and surer than the compound iodine ointment, and 
on that account I never use the latter 



DISEASES OF THE RESPIRATORY ORGANS. 233 

D.— THYMUS GLAND. 

As the anatomy and physiology of the thymus gland have already 
been discussed on page 3, there only remain to be mentioned the 
few pathological appearances which in rare instances occur in it. 

As regards asthma thymicum, it has already been stated, in the 
section on spasmus glottidis^ that the size and position of the thymus 
gland probably have no influence whatever upon the spasms of the 
glottis, for in many autopsies the gland has often been found large, and 
then again small. But the name astJxm,a thymicum, Koppii is doubly 
incorrect : (1), because the thymus has nothing to do with the asthma ; 
and (2), because long before Kopp^ who pubhshed his work in 1829, 
the greatest authorities, such as Morgagni^ P. Frank, Allan Burns, 
etc., sought to establish the view that the thymus may produce suffo- 
cative attacks. 

In new-born and in still-born children F. Weber found small haemor- 
rhages into the parenchjona of the thymus. They have been observed 
singly and in multitudes, associated with intense hyperaemia of the 
entire organ, and generally do not attain to a size larger than a pin's 
head. Usually ecchymoses are also found in the other organs. Weber 
attributes all these extravasations to the act of delivery j^er s<3, and states 
that they are only absent in rare cases, as, for example, where a small 
child was delivered from a large pelvis dead, from any cause which 
could not be ascribed to the circumstances of pressure. 

Tuberculosis of the gland not infrequently occurs ; and even the 
large genuine tuberculous masses, which generally have their site in 
the bronchial glands, have been seen in the thymus gland, while the 
former were free. 

I have twice found carcinoma of the mediastinum anticum in boys 
five or six years old, the lungs, in both cases, being but very little 
implicated ; the pleurae and pericardium were also free, and therefore 
it appeared most probable that the disease originated from the thymus 
gland. 

Affections of the thymus gland, with the exception of carcinoma 
of the mediastinum anticum, which may be detected by extensive 
dulness over the anterior half of the chest, and manifests itself 
by pressure upon the heart, large blood-vessels, and the lungs, can- 
not be diagnosticated ; for the mere existence of dulness on per- 
cussion in the region of the sternum by no means allows a conclu- 
sion to be formed as to the state of the gland. For these anatomo- 
pathological alterations, the symptoms of which are so obscure during 
life as to preclude a diagnosis, no treatment, of course, can be pre- 
sf>ribed. 



234 DISEASES OF CHILDREN. 



E.—L(TJVGS. 



(1.) BiiO^CBiAL OA:rAnnn {Catarrhics ^ronchialis Acutus^ ChroJiU 
cits). £ronchitis. — In the physiological condition all mucous mem- 
branes are covered with a certain amount of secretion, essential to the 
functions of mucous membranes. Now, the bronchial mucous mem- 
brane likewise secretes a certain quantity of mucus, and in fact just as 
much as will suffice to prevent its becoming dry. Every hyperaemia 
of the membrane causes an augmentation of the secretion ; more is 
pom-ed out than can be evaporated, and the consequence of this is an 
accumulation of mucus in the bronchi, which condition has been de- 
nominated bronchial catarrh, or, in severer forms, bronchitis. 

Pathological Anatomy, — Bronchial catarrh may occur either in the 
bronchi of the first and second order alone, the smaller remaining un- 
affected, or conversely ; the principal morbid alterations are found in 
these, while the large bronchi remain normal, or finally the bronchi 
of all orders may be uniformly affected. Both lungs are seldom at- 
tacked simultaneously, a fact more particularly marked in typhus and 
the exanthematous fevers, and seldom only is the catarrh equally in- 
tensely developed throughout the bronchi of a lung. Generally, the 
secretion is most profuse in the lower lobes, and the morbid altera- 
tions of the mucous membrane more marked than at the apices of the 
limgs ; this is probably due to purely mechanical circumstances, the 
greater part of the secretion of the upper lobes descending by its own 
weight into the principal bronchi, while it can only be removed from 
the lower lobes by the action of the ciliae, and by violent expirations 
and coughing. 

The affected portion of the mucous membrane is of a pink-red 
color, where the inflammation has attained a high grade. Its vessels 
present an arborescent injected appearance, and this injection increases 
more and more, and finally in the highest grade becomes so intense 
that the mucous membrane assumes a scarlet-red, velvety appearance. 
A.t the same time it increases in thickness, as may be ascertained with 
the greatest ease by making a few transverse incisions into it, and by 
comparing the incisions of a normal bronchus with those of a catar- 
rhal bronchus, both being of the same order. In, addition the mucous 
membrane appears softened, is easily lacerated, and cannot be pulled 
off in patches from the submucous tissue. 

But the inflammatory redness should be strictly distinguished from 
the redness of imbibition, which is found in all cadavers after 
putrefaction has begun. In morbilli, it is claimed that sometimes the 
bronchial mucous membrane is covered with the same spots as the 
integument ; in small-pox, pustules are met with ia the trachea and in 



DISEASES OF THE RESPIRATORY ORGANS. 235 

the bronchi of the first and second order. The erosions, which ac- 
company chronic bronchial catarrh of the adult, have never yet been 
found in children, even vs^hen they had a cough for many years. 

The secretion is sometimes frothy, and whitish, sometimes only 
permeated by a few air-bubbles, a semifluid, yellowish mass, filling 
up the whole caKbre of a bronchus. Microscopically, it is composed 
of a few characteristic epithehum-cells, most of which are seen to be 
oval without complete angles, and of pus-cells which here are unu- 
sually large, finely granular, and globular. In addition to these in- 
flammatory corpuscles, now and then entire pieces of softened mucous 
membrane are found. 

When a sKght pressure is exercised upon the incised catarrhal 
lung, a drop of this secretion will ooze out from every diseased bron- 
chus ; the number and size of the yellow dots thus produced in the red 
pulmonary parenchyma furnish a means of judging the extent and 
severity of the catarrh. I am unable to decide whether coagulje of 
fibrin also occur in tliis secretion, as some authors state, for I have 
never yet found them. It is remarkable that lungs thus affected do 
not collapse on opening the thorax, on account of the large quantities 
of the accimiulated secretion, which prevent a communication between 
the external air and that in the lungs. In chronic catarrhs, the 
bronchi become somewhat dilated, a condition caused by the super- 
vention of softening and atony of the mucous membrane. But the 
dilatation is always shght, cylindrical, and never cystic ; cystic bron- 
chiectasis never occurs in the infant. In bronchial catarrh one portion 
or another of the pulmonary parenchyma sooner or later generally 
becomes afi^ected in the form of lobar pneumonia, which will be 
specially described in the following section. 

Symptoms. — They are divisible into subjective and objective. 
The subjective only come into consideration in children who are more 
than two years old, and consist of pains along the sternum, to which, 
during cough, a girdle-like pain, corresponding in direction to the 
insertion of the diaphragm, becomes superadded, and sometimes in a 
general malaise, which manifests itself by a depression of spirits, and 
disgust for the customary amusements. The objective symptoms are 
derived from physical exploration, from the kind of cough, the ex- 
pectoration, and the invariable fever. The cough is always the most 
striking symptom ; it alone causes the parents to seek medical assist- 
ance. Generally, the paroxysms of cough are tolerably severe, and 
last from half to one minute, recur several times in the hour, are less 
frequent during sleep, but do not cease completely. Many children 
sleep on, notwithstanding the cough ; others, however, always wake up, 
and from these constant interruptions in their night's rest become very 



236 . DISEASES OF CHILDREN. 

much reduced. The short, abrupt, frequently-recurring, hacking cough 
is very suspicious, for it usually points to the existence of tubercu- 
losis. A bad sign furthermore is, when the children cough more 
when laid on one or on the other side than on the back, for this 
cough too, in most cases, is due to great material alterations in the 
pulmonary structure. Children with simple bronchitis cough less in 
tl^e dorsal decubitus than in the upright posture ; no difference can be 
noted in them between the dorsal and the lateral decubitus. Nor 
is the pain so severe as to cause them to distort the face when 
coughing, or to give other manifestations of pain after the cough has 
ceased. 

The expectoration, so important in adults, enabling us to judge of 
the condition of the lungs, is very seldom seen in children. By the 
sound of the cough it is, indeed, perceived whether any mucus is or is 
not propelled out of the larynx, but, from the hawkings and the rotatory 
movements of the tongue of children from three to five years of age, 
we learn that they do not know as yet how to execute any other 
movement than to regularly swallow doAvn again the sputum that has 
already reached the root of the tongue. Only when the paroxysms 
of cough are very violent, and the mouth is held Avide open, is it pos- 
sible, occasionally, to see the sputa ; they may be often easily ob- 
tained, after a loose covigh, by wiping the root of the tongue with a 
clean piece of rag, to which they will remain adherent. In bronchial 
catarrh, the sputa are either white and frothy or yellowish, and 
then, as a rule, less rich in air-bubbles. They are never colored 
bloody; still, as in every violent exertion, so also from coughing, 
small bleedings may take place from the larynx, fauces, and mouth, 
the blood of w hich, however, is never uniformly mixed with the sputa, 
but always seen in clear single streaks, or in masses. In the majority 
of cases, the expression of the face, in simple bronchitis, is but little 
changed ; since, as a rule, no fever is present, the temperature of the 
head, therefore, also remains unaugmented, and no reddening of the 
cheeks is observable. But, if the bronchitis is very extensive, if the 
bronchi of all orders, in both lungs, are affected, then a very marked 
cyanosis supervenes, for which, when such a child is seen for the first 
time, a different cause is uselessly sought in the circulation. Such an 
extensive affection of the bronchi is extremely dangerous, the respi- 
ration is as labored as in pneumonia, and death ensues usually by suf- 
focation. In the dissection, the pulmonary parench;yTna is only occa- 
sionally found perfectly normal ; generally, lobular pneumonia has 
supervened in several places. 

The physical exploration of the lungs of small children has already 
been commented upon on page 19. All the cautions and deviations 



DISEASES OF THE RESPIRATORY ORGANS. 237 

from the examination of the adult were enumerated there, and will 
have to be kept constantly in view in the following section on the 
various pulmonary affections. The examination of older children — 
those that are over five years of age — differs in no respect from that 
of the adult, but in children of from one to five years the possibility of 
such an undertaking depends entirely upon the conduct of the physi- 
cian. The main point always is, and always will be, to get on friendly 
terms with the child, and then only to commence the examination. 
If the child is immediately ordered to be undressed, and the percus- 
sion and auscultation undertaken without any further precaution, in 
ninety-nine cases in one hundred an uproarious cry will be set up, 
which will not cease till the cause has been altogether withdrawn — 
still more, it will always be set up again as soon as the physician, 
who has created such an impression, returns ; under which circum- 
stances the formation of a correct diagnosis and the institution of a 
rational treatment are, of course, altogether out of the question. 

Percussion in bronchial catarrh gives totally negative results; 
the tympanitic percussion-sound generally is very marked, and the 
physiological dulness on the right side posteriorly, when the abdomi- 
nal organs are pressed upward, is, in small children, very marked 
during bronchitis, for the temporary blocking up of the air in the 
bronchi, by the accumulated masses of mucus within them, is very 
readily effected. 

Palpation is the most useful, and, at the same time, the simplest 
method of examination. In bronchial catarrh, mucus and sibilant 
rales are distinctly felt over the whole thorax, strongest, as a rule, 
over the larynx and trachea, for here the largest mucus-bubbles 
burst, and single tenacious mucus-lamellee are kept in a state of 
vibration by the current of air up and down. If a conclusion were 
formed as to the extent of the catarrh, from the extent of surface over 
which these moist rales are felt, we would very often commit a serious 
error, for, as often as any rales, at all loud, form in the larynx, it will 
be easy to feel them over the whole thorax, and a few active coughs, 
which result in expelling the mucus from the larynx, frequently suffice 
to cause the rhonchi to disappear from the entire chest. Only when 
no rales are felt over the neck, but, on the contrary, are perceptible 
over one side, or over a circumscribed space, then they will not dis- 
appear after so short a time, but will be noticeable for weeks, and 
even months. If any great importance can be at all attached to the 
feeling of the rlionchi, then it is a less favorable sign Avhen they appear 
over a circumscribed spot than Avhen they are diffused over the en- 



238 DISEASES OF CHILDREN. 

tire cliest, inasmuch as, in the first case, the bronchitis has estab- 
lished itself in the bronchi of the third and foui'th order, while in the 
second a single sputum in the trachea, which will be coughed up in 
the next hovu", may possibly be the cause. But if the rales which 
are diffused over the whole thorax are constantly felt for days, and 
even weeks, then it is a proof of the existence of the most extensive 
bronchitis, w^hich is usually already combined with very considerable 
dyspnoea. 

By auscultation we learn, in bronchial catarrh, little more than by 
palpation. By a little practice, the rhonchi may be felt just as well as 
heard ; it is even possible to distinguish the pitch and intensity, and, 
in addition to that, we have the advantage of being able to carry out 
the examination quicker, more accurately, and with less opposition on 
the part of the child, by palpation. Auscultation is desirable mostly 
because by it a complication with pneumonia, which is recognized by 
fine crepitation, and, later, by bronchial respiration, may be diagnosti- 
cated. I cannot participate in the views of some authors, who main- 
tain that fine crepitating rales are heard in bronchitis capillaris. By 
this hypothesis the last distinguishing mark between bronchitis and 
pneumonia would be lost, and the confusion, which is already suffi- 
ciently embarrassing without this, would thus become still greater. 
Where crepitating rales are heard in a child, simple catarrh of the 
small bronchi cannot be assumed to exist, but a pneumonic, alveolar 
disease. The presence of rhonchi of various kinds, and of rough 
vesicular breathing, answers for bronchial catarrh and bronchitis ; 
crepitating rales and, still less, bronchial breathing, ought never to 
occur in this condition. 

The respiration in children with ordinary bronchitis does not de- 
viate from that of the physiological state, but, when the affection is 
very extensive, the respirations become more frequent and laborious ; 
but, as fever generally is superadded, and also accelerates the respira- 
tion, it is difficult to determine how much of the frequenc^y of the 
respiration should be ascribed to the catarrh, and how much to the 
fever. The movements of the alae nasi, which accompany every act 
of respiration, are very rare in bronchitis, and, almost without excep- 
tion, indicate a complication with pneumonia. 

The duration of this disease varies exceedingly, according to the 
cause and the constitution of the child. A child that is not pre- 
disposed to catarrhs may contract a cough through external irritation, 
such as cooling of the thorax, too cold air, injurious and impure at- 
mosphere ; but it hardly ever lasts long, and disappears in a few 
days. On tlie other hand, there are children who, without beinw 



DISEASES OF THE RESPIRATORY ORGANS. 239 

tlio progeny of tuberculous parents, suiFer for years, with only short 
remissions, from bronchial catarrhs ; and, lastly, we have the actually 
tuberculous, who very seldom get rid of it. The prognosis is not 
always to be given as favorably as we should be inclined to assume 
from the general well-being of the child. The simplest bronchitis, 
when it becomes greatly diffused, may eventuate in death by suffo- 
cation ; that founded upon tuberculosis, of course, offers but a very 
unfavorable prognosis. 

Etiology. — There is hardly a child living who has not had a bron- 
chial catarrh in early life, and there is no age at which this affection 
occurs oftener than in that of the first childhood, particularly at the 
time of the first dentition. Thus, for instance, all children cough who 
drivel during dentition, for the garments are perpetually kept wet by 
the saliva, and that produces a cooling of the chest. Bronchial 
catarrh prevails more generally in winter than in summer, in the 
cities and quarters inhabited by the poor, more frequently than in the 
country. Children reared in dusty manufacturing cities usually suffer, 
and children of tuberculous parents so regularly suffer from it that it 
does not at all attract attention, and therefore is not mentioned, if 
special inquiry be not made concerning it. Besides these more 
external causes, there is also a contagion which conveys the bronchial 
catarrh from one person to another, namely, influenza (die Grippe). 
Essentially it consists of a bronchial catarrh, which is ushered in by 
febrile symptoms and anorexia, and spares no age, not even the 
youngest infant. In healthy children, influenza has its regular 
course, and, in from two to three weeks, terminates in complete re- 
covery; in tuberculous children, on the contrary, it often ushers in 
the further development of the cachexia, the children continue to 
cough, become feverish, and finally perish in a hectic condition. 

Bronchitis, furthermore, occurs as a complication in a number of 
general diseases. Thus the bronchial membrane, like the intestinal 
mucous membrane, is implicated in every typhus fever, and, in mild 
cases of febris typhodes, this constant symptom is the most impor- 
tant one in confirming the diagnosis. 

JRohltanshy is even of the opinion that bronchitis (bronchostasis) 
forms the foundation of the exanthematous contagious typhodes, 
such, for example, as occur in Ireland. 

The more detailed views concerning this condition are given on 
page 487, in connection with typhus abdominalis. 

Bronchitis, lastly, is a constant symptom in measles, where it prob- 
ably originates through a morbillous efflorescence of the mucous mem- 
brane, and hence must occur without any exception. It is frequently 
met with in scarlatina, and in both genuine and spurious variola. 



240 DISEASES OF CHILDREN. 

Treatment. — There is no remedy that has a marked direct influ- 
ence upon the course of bronchitis. All the methods of treatment 
hitherto recommended are frequently found to fail. There are prin- 
cipally two symptoms, for the subjugation of which every eflPort 
should be made, namely, the dyspnoea, and the immoderate secretion. 
The first originates through the accumulation of the bronchial mucus, 
with the removal of which it also disappears, and the best means for 
effecting this is the act of vomiting. It is not necessary to give 
strong emetics, for, by these, vomiting is produced too rapidly, and 
the retchings, which in reality are the most important results, by no 
means stand in direct relation to the size of the dose. A very good 
means of inducing protracted retching and vomiting consists in the 
administration of a strong infusion of ipecacuanha ( 3 j to water 3 j), 
of which even one teaspoonful has the strongest effect without impli- 
cating the alimentary canal. If, during and after vomiting, no large 
quantities of mucus are expelled, and if the breathing does not 
thereby become easier, any further emesis will prove useless, and 
will only give rise to a chronic gastric catarrh, by which the child is 
very much reduced. As to the class of expectorants, the vegetable 
ones only are recommendable, and even these should only be used 
in cases where no disturbance of the digestion exists. When the 
latter superv^enes, the harm caused by the expectorants is more ap- 
parent than their very problematical usefulness, and this remark is 
especially applicable to the antimonials, tartar etnetic, sidphuret of 
antimony^ Jcermes-mineral, and white oxide of antimony. Muriate 
of ammonia, so much in vogue in bronchitis of the adult, usually is 
not administrable to children in any form. In acute catarrh of the 
bronchi of infants, a mild infusion of ipecacuanha (gr. j to water | j), 
with a little oxymel simplex^ or a very dilute solution of hall carb. 
(gr. ij — 3 j) are the most appropriate remedies. Little very highly 
recommends frictions of the chest with turpentine ever}' two or three 
hours, and covering of the chest with flannel. When the paroxysms 
become spastic, antispasmodics and narcotics are indicated, which not 
only exercise a favorable abortive effect upon the severity of the 
cough, but also upon the course of the disease generally. Chief 
among these is aq. amygdal. amar., given in two or three times as 
many drops pro dosi as the cliild numbers years of age, three or four 
such doses daily ; next laudanum, in doses already mentioned, several 
times ; ext. belladonna, gr. -^ to -^, several times daily, etc. 

When tuberculosis is at the bottom of the catarrh, this treatment 
of symptoms, as a rule, proves entirely fruitless. In these cases 
ol. jecor. iron and qidjiine must be tried. Pulv. cinchona, given in 
quantities such as can be taken up on the point of a knife, can be 



DISEASES OF THE RESPIRATORY ORGANS. 241 

idministered to almost all children, and I have frequently seen very 
suspicious bronchitis, accompanied by febrile exacerbations and ema- 
ciation, disappear under a continuous employment of this remedy for 
from four to eight weeks. The temperature of the room in which the 
little patient is confined should be uniformly warm, the garments 
warmer than those worn in health ; the drinks should be plentiful, so 
that a beneficial perspiration may be established. If the cause of 
the catarrh still continues, its removal, of course, must be attended 
to ; it should be particularly insisted upon not to allow the children to 
remain in dusty manufacturing cities, as is so often the case with the 
laboring classes. 

In order to guard against further bronchial catarrhs, and to coun- 
teract the disposition to that disease, a systematic inuring is to be 
urgently recommended. As regards the clothing, no definite direc- 
tions can be given ; at any rate the garments should not be so warm 
as to make the children feel uncomfortable, and cause them to per- 
spire profusely on taking a little exercise. More catarrhs are un- 
doubtedly produced by these warm dressings than prevented. The 
best and most rational means of inuring is to sponge the whole body 
with cold water before the child retires for the night ; this may be 
commenced with immediately after the eruption of the canine teeth. 

(2.) LoBULAE AjStd Lobar Inflammation of the Lungs 
[Pneumo^iia Lohularis et Loharis). — Pneumonia occurs extremely 
frequently in children, generally, however, in a form which anatomo- 
pathologically presents a diiferent picture from that which we 
are in the habit of finding in the autopsies of adults. Namely, 
the Imigs do not become extensively inflamed, throughout one or 
more lobes, but only in some places scarcely of the size of peas, 
between which normal pulmonary tissue is found in tolerable quan- 
tities, a process that has been correctly described as lobular pneumo- 
nia. Lobar pneumonia, it is true, also occurs, but comparatively 
much less frequently ; it may come on idiopatliically, or be produced 
by a l)low, as in the adult; usually, however, it is like pleuritis 
of the new-born child, of a pygemic nature. In the latter case it al- 
ways terminates fatally ; the prognosis, on the whole, even in lobar 
pneumonia, not of a pya3mic character, is also extremely unfavorable. 
In the nursling, lobular pneumonia is an extremely frequent affection, 
and carries off many children, especially during the period of dentition. 
In fovmdling-hospitals many children die from it, and the horizontal 
posture in which these cliildren are kept both night and day has 
been considered the chief cause. "What tends to confirm this view is 
the circumstance that, in most of the autopsies, the posterior and low- 
est portions of the lungs, and consequently the most depending parts, 



242 DISEASES OF CHILDREN. 

have been found oftenest affected. Moreover, it has been statistically 
demonstrated that many more children suffer from it in winter than in 
summer, and that a part of the lung is never found with lobular in- 
flammation to which the bronchi leading to it do not also exhibit a con- 
siderable degree of catarrh. The relation of lobular pneumonia to bron- 
chial catarrh is probably of such a character that the gravitating se- 
cretion acts as an irritant, and perhaps mechanically upon the region 
in which the affected bronchi terminate, and that at the irritated 
places small pneumonire develop themselves secondarily. We have 
here, therefore, the relation of cause to effect. This condition also 
arises in most cases of croup, and lobar pneumonia is about as fre- 
quent here as lobular pneumonia, and the extension of the false mem- 
branes — whether they are thick or thin, confined to small or large 
surfaces, or extend far down into the bronchial tube on all sides — ^has 
no particular influence upon the origin of pneumonia. It is also found 
in almost all the cadavers of children who have succumbed to sclerema, 
and often it supervenes as the closing scene in tuberculous lungs. 

Pathological Anatomy. — The anatomo-pathological processes are, 
as the names already designate, of two kinds, and lobular pneumonia 
is distinguished from lobar, not only as regards the extent but also as 
regards the quality of the exudation. 

Lohar pneumonia^ with the exception of the metastato-pyaemic 
form, occurring in lying-in and foundling-hospitals, is remarkably rare 
in the nurshng, but wherever it does occur it displays the same morbid 
alterations as in the adult. Here also we have a red and gray hepa- 
tization, according to the time of the occurrence of death. The exuda- 
tion is not poured out between the pulmonary alveoli nor into their 
walls, but into the cavities themselves, filling them up completely, and 
having the properties of purely croupous exudation. The red hepatized 
lung does not collapse on opening the thorax, it is totally emptied of 
air, the cut surfaces are dry and brownish red, mostly uniformly granu- 
lar, and such portions of the lungs are as friable as the parenchyma of 
the liver. The granular quality of the section is produced by the elas- 
tic fibres lying between the alveoli, which are swollen by the deposit 
of firm exudation. The red color of the exudation is due to the inter- 
spersion of blood-corpuscles. 

The exudation, which, with the exception of the blood-corpuscles, 
primarily was amorphous, becomes quickly transformed into albumi- 
nous and muculent masses ; cells soon begin to form, which are produced 
alike from the alveolar walls and from the exudation. The blood-cor- 
puscles meanwhile are undergoing dissolution, their coloring matter 
disappears, the entire mass changes its color, grows pale — gray hepa- 
tization — and the exudation constantly grows more like pus, on account 



DISEASES OF THE RESPIRATORY ORGANS, 243 

of whicli the French physicians have also called it infiltration purulente. 
Finally, the contents of the alveoli dissolve to a milk-like consistency, 
and are immediately absorbed, and then the rather rare process of a 
complete restitutio in integrum occurs. Occasionally large abscesses 
form, and still more rarely complete obsolescence, hardening, and in- 
duration, of the pulmonary tissue take place. In children lobar pneu- 
monia never degenerates into tuberculous, as sometimes occurs in the 
adult, for tuberculous children generally succumb in the first few days 
after having acquired the croupous pneumonia. 

Lobular pnewtnonia is not a croupous, but a catarrhal inflamma- 
tion. Here small spots in the healthy pulmonary parenchyma become 
diseased, which, although they sometimes aggregate, nevertheless do 
not present the morbid appearance of the croupous lobar pneumonia. 
Generally, the disease involves both lungs, the right more than the 
left, and the posterior parts of the lower lobes are oftenest afifected. 
Such lungs do not collapse completely, and this is not due so much to 
the lobular pneumonia as to the bronchial catarrh that constantly ac- 
companies it, and when they are felt in different directions a few hard 
nodules will be found near their surface or deeply within them. If 
these nodules are now divided, bluish-red, denser spots, without sharp 
circumscriptions, will be seen in the transverse section. The walls of 
the pulmonary air-cells are intensely swollen, and, when they are 
scraped with the scalpel, a reddish, muculent, but sparsely-frothy secre- 
tion is obtained. The lobules affected with pneumonia seem to be 
somewhat beneath the level of the surface, on account of the pulmo- 
nary tissue surrounding them being mostly emphysematous, and their 
darker color makes them easily recognizable. If such places are care- 
fully cut out, so that no normal pulmonary substance remains attached 
to them, they will sink completely in water, and do not present the 
least trace of crepitation. But, by inflating the whole lung, they again 
become filled with air to a certain extent, in contradistinction to the 
croupous pneumonia, in which inflation has no effect whatever; still 
these inflated lobules always retain a darker-red color, and a percep- 
tible hardness. The microscopical examination shows that the pulmo- 
nary vesicles are filled with large quantities of newly-formed epithelium- 
cells and fluid exudation. We have here, therefore, no red and no 
gray, in fact, no hepatization whatever, for which a firm, solid exuda- 
tion is always necessary, and hence also no different stages. Even 
when lobular pneumoniae become confluent, the lobules are neverthe- 
less distinguishable from croupous lobar pneumonia, by the absence of 
friability, by the possibility of forcing air into them by inflation, by 
the greater moistness, and by the remaining free parts which at aU 
times are interspersed between those affected. The process always 



24:4 DISEASES OF CHILDREN. 

remains catarrhal, never becomes of a croupous nature. "When pneu- 
monia is superficially located, we find in addition exudations upon the 
pleura, and invariably bronchitis in the bronchi leading to the inflamed 
places. The secretion in the arachnoid sac of the medulla spinalis is 
said to be augmented. The most common complications are thrush, 
enteritis folliculosa, and sclerema. 

Symptoms. — The symptoms of lobular and lobar pneumonia may 
be very properly described together, since all the signs, with the ex- 
ception of one, furnished by percussion, differ but little from each 
other. In the following description, children under two years are re- 
ferred to : children who have passed the first dentition seldom suffer 
from lobular pneumonia. They usually have lobar pneumonia, which 
differs in no respect from that of the adult. The j^hysical diagnosis of 
infantile pneumonia is attended by great difficulties, and requires much 
patience and time. The children are invariably opposed to the exami- 
nation, and set up such a cry as to render all investigation impossible. 
Added to that, the sputa are also entirely absent, and by their very 
absence demonstrate their importance in the confirmation of the diag- 
nosis. For this deficiency, however, we are indemnified by the char- 
acteristic appearance of the child, and a very peculiar kind of respira- 
tion, whose presence is so characteristic that with a little practice it is 
possible to diagnosticate such an infantile pneumonia even before the 
child is undressed. 

It is seldom possible to accurately establish the commencement of 
a lobular pneumonia, for a bronchial catarrh always precedes it for 
some time, and its transition into pneumonia does not take place at 
once. It is generally ushered in by a cough, without fever, which 
grows worse and worse ; sooner or later fever supervenes, the tempera- 
ture of the skin constantly rising higher, and in a few days the whole 
train of symptoms of pneumonia is fully developed. 

The most striking symptom is great acceleration of the breathing, 
which may rise to sixty and eighty per minute, and have an inverse 
rhythm. While in health the accent lies upon the inspiration — if the 
respiratory sounds be at all audible — in pneumonia, the accent falls upon 
the expiration, which is accompanied by a louder noise than the inspi- 
ration. The most energetic contractions of the diaphragm are now 
seen. At every respiratory act the intercostal spaces sink, producing 
a momentary depression beneath the nipples, extending toAA'ard the 
sternum. In a higher grade of pneumonia, the facial muscles also 
participate, the aliB nasi rise — a phenomenon upon w hich too much at- 
tention cannot be bestowed — the mouth is opened, the angles of the 
mouth are drawn downward and outward, indicative of siifiering, and 
the eyes glassy, staring, or anxiously rolling about. 



DISEASES OF THE RESPIRATORY ORGANS. 245 

These symptoms of the respiratory modus, and the facial miiscles, 
are not more pregnant with information than are the results derived 
from the physical examination fruitless. 

Percussion gives a purely negative result in lobular pneumonia ; 
in the lobar form, marked dulness is found over the inflamed places — a 
dulness which, in contradistinction to the physiological dulness during 
abdominal pressure, may be demonstrable without percussion, both 
during the inspiration and the expiration. That this physiological dul- 
ness posteriorly on the right is very frequently confounded with the 
pneumonic dulness is but too evident, from the fact that it is expressly 
stated in all the text-books that croupous pneumonia establishes itself 
by preference in the right lower lobes. 

Also the rapid and generally favorable course that is ascribed to 
and claimed for pneumonia in the yearly reports of children's hospitals 
and nurseries, shows tolerabl}' plainly that the error is of frequent 
occurrence. 

The rest of the precautions that are to be observed in percussion 
have already been stated in the general part, page 21. 

By auscultation^ fine crepitating rales may be detected in lobular 
pneumonia ; but by this we do not intend to say that no pneumonia 
exists wherever these are absent, for the dense places which give rise 
to them do not always lie near the periphery. Added to that, bron- 
chial catarrh is always present, the sonorous rales of which often mask 
the much less audible crepitations, and the latter are also inaudible 
when the affected places are very much scattered between large por- 
tions of healthy parenchyma. As they are usually perceived within a 
small circumference only, a very close examination of the entire dorsal 
surface is, therefore, necessary for this purpose, which, in restless chil- 
dren, or in those that have once been disquieted, is impossible, even 
with the utmost patience and perseverance. Sibilant rales are in- 
variably heard over both lungs. Crepitating rales is a valuable sign 
in confirming the diagnosis ; their absence, however, does not exclude 
pneumonia. 

In lobar pneumonia, fine crepitation, as in the adult, is heard at 
first; then, for several days, distinct bronchial breathing, strong con- 
sonance of the cough, of the voice and rhonchi, and, thereupon, crepita- 
tion again ; till finally, at the end of eight or nine days, in case of re- 
covery, normal vesicular respiration returns, if the still-existing bron- 
chial catarrh does not produce for some time diffused sonorous rales. 

^■^ palpation nothing but sonorous rales are felt in lobular pneu- 
monia ; the vibrations of the thorax, caused by coughing and crying, 
are alike on both sides. In lobar pneumonia, stronger vibrations of 
the cough, of the rhonchi, and of the voice, are felt over the parts cor- 



246 DISEASES OF CHILDREN. 

responding to tlie dulness, or they are not to be felt at all if the bron* 
cbi leading to the solidified lung are momentarily occluded by mucus. 
Palpation of the thorax cannot be too zealously practised, for in 
the crying child it is the only means which can be employed with 
benefit. 

The cry of children suffering from pneumonia is characteristic : it is 
never very loud, and still less continuous ; it should rather be called 
abruptly-interrupted moans and groans. The cough is frequent and 
persistent in all cases ; when it becomes violent and paroxysmal, little 
white foam appears between the lips, even in the youngest children ; 
generally, how^ever, no expectoration w^hatever is to be seen. The 
cough is distinguished from that in bronchial catarrh by being appar- 
ently productive of pain, the children groaning pitifully after each 
paroxysm, and, at the same time, distorting the countenance in evidence 
of suffering. 

The general symptoms vary according to the extent of the disease 
and its complications. The fever of lobular pneumonia usually begins 
after protracted feverless vespertine bronchial catarrh, disappears in a 
few hours, only to return with greater frequency and violence, till 
finally it becomes continuous. The skin is felt to be hot and dry, but 
the feet are cold and difficult to be warmed. The pulse becomes un- 
commonly rapid, and may rise to two hundred beats per minute. 
That is the utmost limit which, by any practice, it is possible to 
count. 

In most cases of lobar pneumonia, the fever begins suddenly, even 
before the symptoms of disturbed respiration become apjjarent, and is 
as severe as in the eruption of an acute exanthema. On the following 
day the pneumonia comes on, and assumes its cyclical course. The 
consecutive cerebral symj^toms do not depend upon the extent of the 
pulmonary affection, but upon the individual irritability. There are 
children who, in the most violent lobar pneumoniae, retain a free sen- 
sorium, and others, again, who in the slightest ailment are attacked by 
all sorts of convulsions and nervous phenomena. 

There is complete loss of appetite, the thirst is great, and the 
secretion of urine corresponds to the amount of liquids drank. The 
stool is frequently diarrhoeal, because the majority of those affected 
with pneumonia suffer fi'om the effects of dentition, and these, as a 
rule, are attended by loose stools. As this is often a result of the 
treatment, the impropriety of such treatment will be discussed more 
in detail in the future. 

The course is extremely rapid in lobar pneumonia, for death or im- 
provement ensues in from six to eight days. In young children the 



DISEASES OF THE RESPIRATORY ORGANS. 247 

fatal termination is more frequent than recovery. Children over two 
years of age bear lobar pneumonia as well as adults. It is difficult to 
determine the commencement of a lobular pneumonia, on account of its 
gradual development from a simple bronchitis, which must have pre- 
ceded for at least four or five days, but may have existed for weeks 
and even months. Its course is by no means cyclical, sometimes 
rapid, and attended by such pronounced symptoms, that every lay 
person is able to recognize an alteration in the lungs, sometimes so 
gradual and insidious that it escapes the most experienced diagnosti- 
cian. Such children seldom recover completely in less than two or 
three weeks, but, when it tends to a fatal termination, all the symp- 
toms become aggravated, the dyspnoea and the frequency of the pulse 
increase, the extremities become cool, the nails cyanotic, the facial 
muscles distorted more and more, and now the expirations are not par- 
ticularly accentuated. Finally, the respirations grow more infrequent, 
become gurgling or gasping, and death takes place by convulsions. 
In lobular pneumonia, which seldom occurs before the second or third 
week, JBouchut lost thirty-three out of fifty-five patients, ranging 
from a few days to two years of age. According to Valleix, all the 
new-born children in the Parisian foundling-hospital attacked by this 
disease die (out of one hundred and twenty-eight children one hundred 
and twenty-seven died). Trousseau has described, as a most unfavor- 
able prognostic sign, the swelling of the veins of the back of the hand. 
This sign is significant, in view of the fact that the cutaneous veins can 
only be seen in emaciated children, and that these children rarely re- 
cover from pneumonia. In robust children who perished by this dis- 
ease, I never observed any swelling of the veins of the hands during 
its entire course. 

Treatment. — Since every pneumonia is preceded by a bronchial 
catarrh, it is evident that in young children it ought never, under any 
circumstances, to be slighted. Those measures recommended in the 
previous section are immediately to be resorted to. The patients 
should be kept in a uniform temperature ; should not, even in summer, 
unless the air is perfectly still, be carried out of the room ; and should 
be kept warm and dry, especially about the chest. Internally, small 
doses of opium, belladonna, or aq. laurocerasi, are very appropriately 
given. This treatment, -wnth strict surveillance, must be continued 
until the last traces of cough have disappeared. Whoever has treated 
many children with lobular pneumonia, and has seen the much-praised 
remedies disappoint expectations, will not regard this minute and 
careful prophylactic treatment of a simple bronchial catarrh as pedan- 
tic and over-anxious. It is necessary to become habituated to regard 
the bronchial catarrh of every teething child as the possible beginning 



2j|:8 diseases of children. 

of a pneumonia. Too often, unhappily, experience will prove that this 
view is a perfectly justifiable one. 

Abstraction of blood is still pretty generally recommended in both 
lobar and lobular pneumonia, when already fully developed, and 
leeches are resorted to for that purpose with especial preference, for 
cupping" is too painful, and, on the small surfaces of the thorax, their 
application is rendered diflScult. Phlebotomy is usually impracticable, 
on account of the smallness of the cutaneous veins and the density of 
the subcutaneous fascia. Two or three leeches are therefore applied 
around the nipple, upon the sternum, or, according to Souchiit, on 
the inner surface of the thigh ; the subsequent haemorrhage to be 
encouraged for an hour. For the last five years I have not employed 
them at all, and must confess that, since then, I am more satisfied 
with the results of my treatment. I have frequently had opportunities, 
in consultation, of observing children in whom leeches had been em- 
ployed by physicians differing from my vicAvs in regard to the ab- 
straction of blood, and can report nothing favorable whatever of the 
course of pneumonia treated in that manner. Most of the children 
were prostrated and anaemic, the lips were blanched and ej'elids pale, 
and, although temporary mitigation of their dyspnoea was said to 
have resulted, no such improvement was to be seen on the second day 
after. This treatment can be regarded as abortive in no other sense 
than that these children die sooner than those treated on the ex- 
pectant principle. When this treatment is followed by recovery, con- 
valescence lasts very decidedly longer, they retain their pale color 
and angemic appearance for a long time, and iheir development is 
much retarded. Therefore, since I have never yet seen any marked 
benefit, but, on the contrary, very lamentable effects, produced by 
leeches, it Mould be totally inexcusable on my part not openly and 
directly to protest against the practice of abstracting blood. 

And I may say the same of the much-lauded tartar emetic, which 
men, in other respects of soimd judgment ( Vdlleix, for instance), extol. 
Intestinal catarrh, according to the most extensive experience and ob- 
serv'ation, is the most frequent complication of pneumonia, and all 
those remedies are therefore to be avoided which are liable to pro- 
duce it. The chief of these is tartar, stibiat., which, particularly in 
small doses, insufficient to induce vomiting, almost invariably produces 
a diarrhoea that is difficult to arrest. The injuiious effect of this agent 
upon the intestinal canal is earHer and more surely manifest than its 
favorable antiphlogistic and expectant action. In this respect, even 
ipecacuanha, although much less frequently, may do harm, yet the 
diarrhoeas following it are of much shorter duration, less pernicious, 
and easily controlled by small doses of opium. In dyspnoea and suf- 



DISEASES OF THE EESPIRATORY ORGANS. 249 

focative attacks, a few teaspoonfuls of a strong infusion of ipecacu- 
anha ( 3 j to water 3 j) act decidedly favorably, but even tliis should 
not be given more than once in twenty-four hours, at the utmost. 
Diarrhoea must be arrested immediately by small doses of laudanum, 
one drop pro closis, for example. A weak infus. ipecac, (gr. j — ij to 
water 3 j) causes neither vomiting nor diarrhoea, and therefore, in this 
respect, is harmless ; but whether the expectoration of the catarrhal 
secretion is thereby materially facilitated is another question. It 
may be safely stated that the changes in the kind and severity of the 
cough following its administration are not very striking. 

When the skin is burning hot, and no diarrhoea is present, I give 
one-eighth of a grain of calomel, four or five times daily, until gTeen, 
semi-fluid stools ensue ; after that a simple mucilage of gum-arabic, 
with a little syrup simpl, and tr, opii gtt. j — ij, until constipation 
is produced. The infus. ipecac, is avoided as long as possible, but 
may be prepared and preserved in a cool place till required. In cases 
where the dyspnoea increases rapidly, a large quantity of bronchial 
mucus is often suddenly expelled by an energetic act of vomiting, and 
in this manner very apparent palliation is frequently obtained. In all 
cases, the local treatment consists in the application of a moist girdle, 
in the folloAving manner : A diaper, or a large white pocket-handker- 
chief, is folded up hke a cravat ; the bandage thus obtained should 
be three or four fingers wide, and the whole length of the handker- 
chief. This is now dipped in tepid water, and wrung out so that the 
cloth does not drip, and then applied, like a girdle, around the chest 
of the child. A second cloth, double the size of the first, is folded up 
in the same manner like it, but which must be six to eight fingers 
broad, and then applied, dry and warm, over the first. It is very ad- 
visable to interpose a piece of gutta percha between the dry and the 
wet girdle, by which, on the one hand, the moistness of the first cloth 
is preserved longer, while, on the other, the second does not become 
wet. If the water with which the fomentations are made is not too 
cold, the child will tolerate them very well, and, in a short time, a 
slight retardation in frequency and improvement of the respiration 
are indicated by less motion of the al aenasi. These tepid compresses 
should be continued for from four to six days, and it is not at all neces- 
sary, during the entire time, to remove the bandage ; the gutta percha 
is raised up a little, and a few teaspoonfuls of Avater are poured upon 
the girdle, or it is moistened with a sponge. The principal thing is not 
to allow a cooling of the skin by evaporation to take place. To secure 
this object, the dry cloth should properly overlap the moist one on all 
sides, and, as it is impossible to prevent the upper cloth from becoming 
wet, it should be changed several times during the day. I certainly 



250 DISEASES OF CHILDREN. 

have applied this girdle many hundreds of times, and have very often 
seen rapid improvement ensue ; nevertheless, it cannot be denied that 
the half of these children perish notwithstanding. If cold compresses 
are applied to the children, as recommended by some authors, a cry 
of fright is the consequence ; the child is seized with a feeling of dread, 
the breathing is palpably accelerated, and does not subside until the 
cold water has become warm through the temperature of the skin. 
Hence it seems more rational to make the compresses warm at once, 
by using warm water, in order to avoid the temporary restlessness 
and discomfort to the child.* 

(3.) Acquired Atelectasis or the Ltjkgs. — Congenital atelec- 
tasis has already been treated of (on page 57) in connection with the 
diseases which are regarded as the immediate effects of the delivery ; 
it therefore only remains for us to speak of the acquired atelectasis. 
This affection has the most intimate connection with rachitis of the 
thorax, and therefore mostly occurs in children between the ages of six 
months and three years. In many cases the augmentation in the den- 
sity of the pulmonary tissue and the final atelectasis are due to a marked 
curvature of the spine, to a distended pericardium, hj-pertrophied heart, 
to aneurisms or neoplasms. It is found most exquisitely marked in 
pleuritic exudations, where the lung is compressed to the thickness of 
a finger and correspondingly condensed. 

Pathological Anatomy. — The degrees of atelectasis vary exceed- 
ingly. A mere increase in the density may occur, which is recognized 
by the augmented consistency, but the compression may also attain to 
such a high degree as to cause a total obhteration of the alveoli, and 
the disappearance of the capillary vessels. At first these compressed 
and atelectic places contain blood and have a great similarity to muscle, 
on account of which this condition has been called camification ; but, 
when it has existed for some time, they become bluish brown or gray, 
shrink up into a leathery rind, the pulmonary tissue cannot be recog- 
nized, and is converted into a fibro-cellular mass, which is gradually 
displaced by the slightl}^ emphysematous surrounding parts, and ulti- 
mately disappears altogether. Such soHtary atelectic places are very 
rarely found, at least, in older children and adults. Sometimes it is still 
possible to inflate such atelectic places, if they are of but recent forma- 
tion ; generally, however, this experiment proves fruitless, for the alveoli 
have actually disappeared, and been replaced by a fibro-cellular mass. 

When the lesion is extensive, it ^^oll have a similar effect upon the 
circvilation as pulmonary emphysema. The capillary circulation be- 
comes so impeded here, that a stasis takes place in the trunk of the 
pulmonary artery, producing dilatation of the right side of the heart, 
and finally venous stagnation and cyanosis. 

* See treatment of typhus fever, page 493. 



DISEASES OF THE RESPIRATORY ORGANS. £51 

The cause of acquired atelectasis is therefore chiefly to be sought in 
the rachitic thorax ; the latter, however, originates in the following 
manner : The inspiration is brought about by the contraction of the in- 
spiratory muscles, and a dilatation of the pulmonary vesicles is thereby 
produced. A momentary rarefaction of the air witliin them results, 
which helps to overcome the atmospheric pressure which is becoming 
stronger and stronger upon the thorax, aided by the elastic pulmonary 
tissue, which drags inwardly at every inspiration. The combined effects 
of these forces is an inward curving of the intercostal spaces, and, in 
lean persons, of the clavicular region also. I was once able to see 
this condition most strikingly displayed in a child in whom a rib 
was broken in two places by the shaft of a wagon running against 
it. The fragment of the rib, one and a half inches in length, was 
kept in place by mere skin, and flapped in and out with every inspi- 
ration and expiration, like the valve of a bellows. If the bony ribs 
have lost their firmness by being deprived of some of the calcareous 
salts, they will also participate in the inward movement, which other- 
wise is only seen in the intercostal muscles, and thereby lose their 
external convex shape. Moreover, they also yield to the diaphragm, 
which, by the pressure of the abdominal viscera, drags upon them so 
as to retard their longitudinal growth (producing rachitic shortening 
of the bones). By these various forces is finally produced a distorted, 
contracted, and misshapen thorax, the contents of which necessarily 
must sufi"er, more especially as, in consequence of the curv^ing and re- 
tarded growth of the spinal column, it is also lessened in perpendicular 
dimension. 

Symptoms. — In consequence of the diminished number of pulmo- 
nary cells containing air, an acceleration of the respiration necessarily 
must result, if an interchange of gases corresponding to the bodily 
weight is to take place. The respirations, in fact, are quickened and 
executed with considerable exertion, the alee nasi thereby participat- 
ing. The application of the stethoscope to the rachitic thorax is at- 
tended by many difficulties, for the button-like sternal ends of the ribs, 
and the concavities in the region of the nipples, render a perfect adap- 
tation of the instrument impossible. We almost always have to con- 
fine ourselves to an immediate auscultation of the back, and gen- 
erally hear sonorous rales in all parts, because the bronchi lead- 
ing to the atelectic portions are affected with catarrhal inflammation. 
Over the diseased places proper crepitating rales and bronchial breath- 
ing are heard, provided the sonorous rfdes do not drown all other 
sounds. But on the infantile thorax, and especially the rachitic, the 
vesicular, puerile breathing is so sharp, and the expiration so loud, 
that the distinction between puerile and bronchial breathing consists 



252 DISEASES OF CHILDREN. 

onlj ill a fine modification of the sounds, and the utmost skill is requi- 
site to distingTjisli Avith certainty between the two. 

By percussion it is but rarely possible to demonstrate the atelectic 
places, for, in most cases, they are too small in extent, and very fre- 
quently border on the liver, where, by the incarceration of the borders 
of the lungs between the upper surface of the liver and the inwardly- 
curved ribs, a condensation of the tissue is produced. Besides, we 
must always take into consideration the physiological dulness during the 
abdominal pressure, the rachitic condensation of the scapular portio% 
and the similar condition from the curvature of the spinal column that 
very frequently occurs, before we can ascribe a discovered dulness to 
atelectasis. 

From what has been said hitherto, no difference Avill have been 
discovered between the symptoms of pneumonia and those of acquired 
atelectasis, and in reaUty there is but one sj-mptom by which we are 
enabled at the very first sight to discriminate between these two con- 
ditions. In pneumonia a burning hot skin is always present ; in atelec- 
tasis, on the contrary, it is absent. But when, in a rachitic child, with 
acquired atelectasis casually, or from dentition, or some other acute 
afifection, fever becomes superadded, then no one is able to decide from 
one examination as to the correct diagnosis. Only the course of 
the accidental complication, the continuance of the dyspnoea and the 
respiratory modus after the fever has disappeared, can clear up the 
obscurity and aid us in the diagnosis. This diagnostic difficulty is an 
additional reason why pnemnonia should not be treated instantly by 
leeches and antiphlogistics. In all cases such a treatment agrees 
very badly with rachitic children. 

The progress of rachitic acquired atelectasis is always very grad- 
ual ; the course is chronic, and may be prolonged for years. With 
increasing invigoration, and recommencing growth of the ribs, the 
respirations become slower, the strong inward curving of the fourth to 
the eighth ribs decreases with every inspiration, the pigeon-breast 
subsides, the auxiliary respiratory muscles of the neck and alae nasi 
cease to participate actively. 

But if no such consohdation of the thorax takes place after several 
months, and if the atelectasis progresses and implicates still larger 
portions of pulmonary tissue, then the portions that still remained 
normal will be unable to perform the extra amount of labor thus im- 
posed upon them. A still more intense bronchitis is now liable to 
supervene, and the subjects die from paroxysms of suffocative cough, 
after having suffered for weeks, and even months, from the most vio- 
lent dyspnoea. CEdema of the feet precedes death in these cases some- 
times several weeks. 



DISEASES OF THE RESPIRATORY ORGANS. 253 

The prognosis depends upon the degree and the duration of the 
conditions. The more developed the pigeon-breast, the more exten- 
sive the solidification of the tissue, the greater the dyspnoea, the more 
imminent is the danger of the child's being carried off by a slight 
bronchial catarrh, or by hydrsemia, in consequence of defective meta- 
morphosis of the materials. And yet, even very decided disfigure- 
ments of the thorax, and the atelectasis resulting therefrom, are often 
completely recovered from. 

Treatment. — The first question always is that of the nutrition, 
the second that of the residence. As the pigeon-breast only devel- 
ops itself from the sixth to the ninth month, the children are usually 
already weaned and fed upon various kinds of broths and soups. 
However, it is not possible to maintain that any of these methods of 
nutrition are absolutely injurious, for upon all of them great numbers 
of children thrive as well as die ; and it cannot even be decided which 
of these ward off the rachitis best, for it occurs in all kinds of diet and 
all manner of nutrition. The most important point in this relation is, 
that the food should be well borne and assimilated, and that no diarrhoea 
or other kinds of digestive disturbance be produced by it. Children 
with perfectly regular digestion very rarely become rachitic. 

Living in damp houses materially promotes the production of 
rachitis, on account of which it is also much more frequent in winter 
than in summer, and among the poorer class of people than among 
the rich. Consequently, the treatment must be chiefly directed to the 
procurement of well-ventilated, dry rooms, and as long a residence in 
the country as possible. Where these conditions are unattainable, the 
termination will generally be unfavorable. Our efforts to eradicate 
the bronchitis, which invariably accompanies atelectasis, by the use of 
expectorants, narcotics, or any other class of remedies, AviU almost al- 
ways be fruitless. This complication subsides spontaneously, as soon 
as the lungs have again acquired a more capacious and better condi- 
tion. I confine my treatment to inunctions of fat upon the breast, 
several times daily, and internally give ol. jecor., or the malate of iron, 
more precise indications for which will be given further on, in the 
treatment of rachitis. 

(4.) Pflmonart Emphysema {to efi^vG?!fia, to inflate). — Tlie well- 
known blubber-like emphysema of the lungs, from which adult patients 
acquire a barrel-like thorax, and suffer from displacement of the heart 
and diaphragm, is scarcely ever seen in children ; indeed, this kind 
of rarefaction of the pulmonary tissue seems to be altogether absent 
in the infantile organism. On the other hand, a vesicular and inter- 
stitial emphysema is often found under the following pathological con- 
ditions : 



254 DISEASES OF CHILDREN. 

Pathological Anatomy. — Purely vesicular emphysema consists in a 
permanent dilatation of a large section of pulmonary alveoli, which, 
however, are not ruptured, but only distended to perhaps twice their 
normal size. This sj^ecies of alteration of the pulmonary tissue is 
almost invariable in the vicinity of condensed portions ; thus along 
with pneumonia, atelectasis, and tuberculosis, it is often found. Em- 
physematovis lungs do not coUapse on opening the thorax, have a pe- 
culiar feel, like a cushion filled with air, are grayish or yellowish gray, 
anaemic, and, when incised, collapse with a hissing, slightly-crepitating 
sound. When the condition is of long-standing and in progressive 
atrophy of the alveolar walls, interlobular einphysema invariably be- 
comes superadded. 

This condition consists in an accumulation of air in the cellular 
tissue connecting the different pulmonary lobules with each other, and 
can only be produced by the rupture of some of the pulmonary cells, 
and by the escape of air into the adjacent interlobular interstices. 
Larger or smaller transparent air-bubbles then appear on the surface 
of the lung, beneath the pleura, which may be displaced in the direc- 
tion of the interstices, and also ramify into the deeper structures of 
the lung. Sometimes they circumscribe a pulmonary lobule, in the 
shape of an island, and, when the interlobular emphysema has devel- 
oped itself between many neighboring lobules, form large air-bubbles, 
w^hich may be pushed hither and thither over extensive portions of the 
pleural surface of the lung. The escape of air into the connective 
tissue surrounding the bronchi, into the mediastinum anticum, and 
thence out upon the neck and breast, is a very rare occurrence. These 
instances almost invariably terminate fatally. 

In regard to the origin of the ordinary emphysema, many, and in 
part untenable, views still exist. It is certain that solidification of one 
portion of the pulmonary parenchyma will produce a vicarious vesicu- 
lar emphysema of the rest of the tissue, and that, in the autopsies of 
atrophic children, principally as the effects of enteritis folliculosa and 
cholera infantum, interlobular emphysema is usually found. I have 
formed no positive conclusions upon the occurrence of emphysema from 
pertussis, as stated in so many text-books ; on the whole, I am unable 
to recall a single instance of ever ha\dng met with it in the autopsy of 
a child who died from pertussis or any of its complications. Rilliet 
and Sarthez also are opposed to the recognition of this complication ; 
and it follows from this that, aside from the mechanical distention 
of the alveoli, which, in forced expiration, too, may be produced at 
the expense of the amount of blood in the lungs, still another special 
disturbance of the nutrition of the alveolar walls must be present, 
without which, notwithstanding all exciting causes, no emphysema 



DISEASES OF THE RESPIRATORY ORGANS. 255 

could be brought about. The inflation of air, in asphyxiated new-born 
children, has been suggested as an additional cause, but which is not 
very probable, in view of the fact that the lungs of the new-born 
child may be inflated, after death, with all the strength possible, with- 
out rupturing their air-vesicles. The lungs are so distensible, and, by 
forced inflation, may be enlarged to such a degree, that one lung will 
fill up the entire thoracic cavity, and yet, as soon as the air is allowed 
to escape, it collapses again, without leaving the least trace of em- 
physema behind. 

Symptoms. — In children, the barrel-like shape of the thorax never 
develops itself, because, as it appears, they scarcely ever sufier from 
chronic, but always from acute emphysema, and, for that reason also, 
that depressed state of the diaphragm is not produced. Hence, we 
have no physical signs for it, and it is a very great question whether 
the acceleration of the respiration, mentioned in the text-books, had 
not better be imputed to the pulmonary afliections producing the em- 
physema than to the emphysema per se. This condition, therefore, is 
only of anatomo-pathological importance. The prognosis and the 
therapeutics, in a disease in which the diagnosis is so uncertain, are, 
of course, altogether out of the question. 

(5.) OEdema PuLMONirM {oid7jfj.a, a swelling). — In most of the dis- 
eases of the heart, of the large vessels, and of the lungs, a rapidly-fatal 
pulmonary oedema supervenes as the final pathological state. Then, 
of course, it has but little importance as a pathological condition, and 
is only to be regarded as the beginning of death. On the other hand, 
in measles, and more frequently in scarlatina, a rapidly-developed pul- 
monary oedema is met with. It does not, however, always lead to 
death, but disappears spontaneously or by proper remedies. It is to 
this latter form in particular that our attention is to be directed here. 

Pathological Anatomy. — By pulmonary oedema we understand a 
transudation of serum into the pulmonary alveoli, the finest bronchi, 
and into the interstitial tissue. Neither the first nor the last alone 
can become infiltrated with serum without the participation of the 
others ; and the disputes of some authors, whether the oedema has its 
site in the alveoli, or in the interstices, may therefore be decided in 
favor of both. (Edematous lungs do not collapse on opening the 
thorax, are of a grayish-blue or yellowish-gray color, according to the 
quantity of blood in the aficcted parts, are heavier than the healthy 
lung, swim in water, and crepitate strongly on pressure. The press- 
ure of the finger leaves a pit behind, for the corresponding pleura is 
also oedematous. On section, the oedematous lung presents a smooth 
glistening surface, from which a large quantity of reddish or yellowish 
fine-firothy serum escapes on the least pressure. The escape of this 



256 DISEASES OF CHILDREN. 

froth is also accompanied by a hissing or crepitating noise. CEdema 
of the lungs is never confined to small portions of the j^ulmonary tissues, 
but generally affects the lower lobes of both lungs, a proof that its 
cause is not a local, but a general one, and that it must be due to a 
disturbance of the circulation. Qijdematous lungs may be inflated, and 
thus it is seen that not all the alveoli are filled with serum. The cor- 
responding bronchi contain mucus, and in the bronchi of the higher 
order a similar frothy serum, like that which oozes out from the cut 
surfaces, is always found. 

Symptoms. — The predominating symptom is a marked dyspnoea, 
which rapidly becomes aggravated to such a degree as to actually en- 
danger life by suffocation, and may terminate fatally in a few hours. 
When the children are already large enough, and when their strength 
allows them, they will raise themselves and sit upright in bed, in order 
to acquire the utmost dilatation of the thorax possible. Small children 
Avhile in the recumbent position are seized with severe fits of suffoca- 
tion, rendering it necessary to raise them up immediately. The breath- 
ing is extremely rapid, gasping, and rattling, and the voice grows low 
and indistinct. The cough is loose ; older children produce also a little 
Avhite foam at the mouth. The pulse is very small, but, as regards 
the nvmiber of beats, stands in no relation to the frequency of the 
respiration. 

In extensive oedema the physical investigation gives a less sono- 
rous but never a completely dull percussion-sound. As oedema of the 
lungs is mostly bilateral, and the dulness not very intense, percussion 
therefore often furnishes no very satisfactory information concerning 
the existing alteration of the lungs. Auscultation is of greater im- 
portance. Extensively-diffused, moist, sibilant rales are heard over the 
oedematous places, which the practised ear readily distinguishes, by the 
coarser and less regular sound, from fine crepitation of pneumonia. 
They are often drowned by the large sonorous rales produced in the 
larger bronchi by the accumulation of mucus within them, but these, 
after a violent cough, momentarily disappear. If a hand is laid upon 
the chest, it wiU feel these rhonchi extremely strong, w^hile crepitation 
usually is not perceived by palpation. It is very difficult to distin- 
guish pneumonia from oedema of the lungs, especially in those acute 
cases of oedema where it is attended by active fever. The dyspnoea, 
if possible, is even greater in oedema than in inflammation of the lungs, 
but the physical examination supplies no characteristic differences ; 
the only symptom that tends to make the existence of oedema tolerably 
certain is the bilateral appearance of crepitation, while lobar pneu- 
monia very generally is only observed on one side. 

The prognosis, if the cause of the condition is not due to cardiac. 



DISEASES OF THE RESPIRATORY ORGANS. 257 

disease nor to a chronic disease of the lungs, is not so unfavorable as 
the first impression would lead one to suppose. Children attacked by 
nephritis and consecutive oedema of the lungs, after scarlatina, fre- 
quently suffer from the most intense dyspnoea, their faces are disfigured 
by swelling, and one supposes that a speedy end may be prognosti- 
cated with certainty ; but after a while they rally somewhat, the albu- 
men and casts in the urine diminish, and at the same time the urine is 
voided in increased quantities. 

Treatment. — For nephritis after scarlatina as a cause of this pul- 
monary affection, the antiphlogistic treatment, with calomel, purga- 
tives, and abstraction of blood, has proved itself to be decidedly injuri- 
ous. The dyspnoea of older children may indeed be rapidly relieved 
by venesection, but it soon becomes as torturing as before, and, antemia 
now having become superadded, the condition will be found to be 
vastly aggravated. A large number of dry cups applied to the back 
and breast mitigates the dyspnoea very considerably, and this remedy 
may be repeated once or twice daily without any harm or special an- 
noyance. The utmost attention is to be paid to the state of the skin, 
which should be made to act energetically. The best means by which 
to accomplish this purpose is to wash it with a highly-diluted solu- 
tion of lye. The secretion of urine, according to the observations 
which I have hitherto instituted, is not stimulated by any remedy so 
well as by the widely-known and popular roob * juniperi, of which half 
a teaspoonful may be given once or twice daily. It has also the ad- 
vantage of having no unfavorable efifect upon the appetite and stools, 
and that, mixed with syrup or honey, children are able to take it 
for a long time. The other diuretics, squills, digitalis, and acetate of 
potash, taste badly and their use is attended by numerous concomitant 
disagreeable effects, and therefore they are much less appropriate than 
rooh juniperi. In the higher grade of dyspnoea an emetic of ipe- 
cacuanha and tartarized antimony often performs very efficient service. 

(6.) H^iioERHAGE FROM THE LuNGS {ScemorrJiagia Ptdmonum 
— SrBnioptysis). — Three kinds of bleeding from the lungs are known 
to occur in the adult — either in the form of bloody sputa for a long 
time, or the blood suddenly bursts out from the mouth and nose in a 
stream, or the patient sinks down in a state of unconsciousness, and, 
after he has regained his faculties, is seized with coughing up of 
blood. In children, so far as I am aware, the second form only oc- 
curs, and is a complication of two very different conditions, whooj)ing 
cough and tuberculosis. In some epidemics of pertussis, large quan- 
tities of blood are very frequently poured out from the mouth and 
nose, but the invariably favorable course, the absence of consecutive 

* See note on page 191. 



258 DISEASES OF CHILDREN. 

bloody sputa and all other bad effects, give rise to tolerably well- 
grounded doubts whether the blood does actually come from the 
lungs, or whether it is not merely the effect of the violent paroxysms 
of cough, and comes from some small lacerated vessels or capillaries 
in the larynx. The last of the two just-mentioned sources seems to 
me, in fact, to be the most probable. 

Pulmonary haemorrhage of tuberculous children is exceedingly 
rare. One may see hundreds of them perish from phthisis pulmonalis 
without meeting with a single instance of haemoptysis, and where it 
does occur it is not always seen at the commencement of the tuber- 
cular process, but as a closing scene a few days before death. I have 
never yet observed it in infants, and only once in older children, and 
that was in a girl ten years old. 

The treatment of hemoptysis, as an effect of pertussis, may be 
found in the section devoted to that subject. That occurring in tuber- 
culous children is only symptomatic, and consists entirely in the 
administration of small doses of narcotics to palliate the cough, and 
for the purpose of procuring euthanasia, 

(7.) H^MOPTOic PuxMOKAET IsTFARCTiox. — This morbid lesion 
of the lungs, first accurately described by Laemiec, is not very unfre- 
quently observed in the autopsies of children who have perished from 
purpiira or pulmonary tuberculosis, and is even found in the new- 
born child, but in the latter it is generally comphcated wdth pyjemia 
and the formation of emboli in the lunofs. 

Pathological Anatomy. — In one lung, and sometimes in both, red- 
dish-black spots, of the size of a pea up to that of a walnut, are 
found, which are sharply defined from the rest of the pulmonary 
tissue, and of decidedly greater resistance. The cut surfaces are not 
dry and smooth, but slightly granular, and the portions of the lungs 
thus altered are almost as friable as the hepatic parenchjnna. The 
cause of this darker color and augmented resistance is to be found in 
an extravasation of blood, which has filled up a large number of al- 
veoli, and compressed the interstitial substance. The slightly-granu- 
lar appearance of the cut surfaces is also explained by the circum- 
stance that the coagulated blood represents a precise cast of the 
cluster-like arrangement of the alveoli. On scraping such a cut 
surface with the back of a scalpel, a bloody fluid, mixed with fine, 
granular blood-coagula, is obtained. 

There is great danger of confounding this condition with croup- 
ous pneumonia. But, if due attention is given to the circumscribed 
form of the haemoptoic infarction, its dark-red color and sharp boun- 



DISEASES OF THE RESPIRATORY ORGANS. 259 

daries, and the dark-red granular serum, whicli may be scraped off 
the cut surfaces, it will then hardly be possible to entertain any doubt 
in regard to the nature of the lesion. When these infarctions have 
become developed between dark-red hypostatic congested tissues, be- 
hind and below for instance, the distinction of color is then lost; still, 
the greater compactness and fragility, likewise the absence of air- 
bubbles, supply sufficient cardinal points. Htemoptoic infarctions are 
oftener central than peripheral, and, in the latter case, ghsten through 
the pleura. The bronchi leading to them, up to a certain grade, are 
filled with coagula ; the blood, however, generally does not extend 
very far upward, and consequently no bloody sputa are expectorated. 

This condition, according to MoJcitansJcy , is often attended by ac- 
tive softening of the right side of the heart, and in severer forms may 
become compHcated with rupture of the pulmonary tissue, when large 
cavities may be seen filled with blood and loose pulmonary substance. 
According to the same author, it is also possible for a retrograde de- 
velopment to take place, the infarction either becoming Hquid, and 
assuming a blackish-brown, or rusty and wine-yeast-like color, and 
thus partly absorbed, partly expectorated by the bronchi, or the coagu- 
lated blood shrinks and is metamorphosed into an obsolete fibrous or 
bro'wn amorphous tissue. In grave instances, the infarction may also 
become gangrenous, and then present the signs of a perfect gan- 
grene of the lungs. 

Symptoms. — Hfemoptoic infarction is never idiopathic, but always 
complicated with purpura, tuberculosis, and cardiac afiFections ; in all 
cases the dyspnoea and fever become vastly aggravated by its appear- 
ance. Neither by physical examination, nor by any symptoms other- 
wise developed, are we able to distinguish this condition from lobular 
pneumonia. Most of the physical signs are devoid of importance, for 
the reason that the infarction usually occurs about the roots of the 
lungs, and not on their periphery. A special treatment in a malady so 
deficient in diagnostic symptoms as this, is, of covirse, impossible. 

(8.) Gangrene of the Lungs [Gangrcena s. Mortlficatio PuU 
momcm). — Gangrene of the lungs is an exceedingly rare affection in 
children. It occurs after traumatic pneumonia, produced by foreign 
bodies, which, during a forced inspiration, have found their way into 
the lungs, and in the mahgnant course of acute exanthemata, in noma, 
in abdominal tjqohus fever, in pysemia, and, lastly, as an unfavorable 
teitnination of hirmoptoic infarction. 

Pathological Anatomy. — Since JOaennee's time a diffused and a 
circumscribed gangrene of the lungs have been distinguished. 

The characters of the diffused are : Spreading of a dirty-greenish 
or browTiish-colored putrid slough over larger portions of a lung, over 



260 DISEASES OF CHILDREN. 

one lobe, or an entire lung, or tlie tissues, ha^dng become totally lique- 
fied, have a gangrenous odor, and are infiltrated with a flocculent, 
froth}^, gangrenous-odored ichor. This kind of mortification is no 
where strongly defined, but gradually merges into healthy structures, 
larger or smaller streaks of oedematous tissue being interposed be- 
tween the gangrenous and sound portions of the lung. It is very 
rarely observed alone, but generally associated with circumscribed 
gangrene. 

Circumscribed gangrene is oftener met with than the preceding. 
In this process, a small portion of the tissues at one place becomes 
transformed into a greenish-black, moist, not easily-lacerable crust or 
slough, which is sharply defined. In the infant, tlie size of this slough 
rarely reaches that of a walnut. After a while this gangrenous plug 
becomes detached from its normal surroundings, and lies in an exca- 
vation of gangrenous pulmonary parenchyma, and bathed by a gan- 
grenous ichor ; or it soon dissolves into a sanious, ichorous fluid, and 
is surrounded by a sloughing excavation, with irregular, shaggy walls. 
Its site is oftener on the periphery, and in the lower lobes, than in the 
centre of the lung, and, after it becomes detached, it will drop into the 
pleural sac, if the pleura is not imphcated and firmly united with the 
costal pleura. This accident results in an ichorous pleuritis, and pneu- 
mothorax becomes developed. 

The pulmonary tissue surrounding the gangrenous plug is either 
only oedematous or pneumonic to variable extents ; in both instances 
there is a disposition to assume a diiFused mortification, and thus, if 
the children have lived long enough with this dreadful disease, an en- 
tire lobe may be found transformed into a pultaceous, sanious mass. 
If the arteries coursing through the afiected places do not become 
completely occluded by thrombi, serious haemorrhage may ensue, the 
blood escajDing by the bronchi, while that which accumulates in the 
gangrenous cavities tends to increase the gangrenous material. No 
recovery from traumatic gangrene of the lung has been ever observed. 

Symptoms, — The symptoms vary according to the cause of the gan- 
grene. In typhus fever, in noma, and malignant measles, the general 
disease is so severe, and the susceptibility to the pain, at the same 
time, so diminished, that no subjective symptoms whatever, and only 
a few objective symptoms, become noticeable, while traumatic gan- 
grene begins wdth the symptoms of pneumonia. I once met with such 
a case, in which a boy, fourteen years of age, had a grain of corn in 
his mouth, and, from some cause or another, suddenly commenced to 
laugh, during which the grain slipped into his larynx. For several 
days thereafter he was still tolerably well, and it was supposed that 
he was mistaken, and that he had swallowed the com. But all the 



DISEASES OF THE RESPIRATORY ORGANS. £61 

symptoms of pneumonia at length suddenly came on, but did not run 
the regular course. The sputa became gangrenous, and, through vio- 
lent paroxysms of coughing, the patient expectorated portions of the 
grain of corn, and large quantities of sloughing shreds, whose odor 
contaminated the atmosphere of the room to an unbearable degree. 
This expectoration continued for several weeks, and did not stop 
completely until after many months. The boy was reduced to a 
mere skeleton, and a cavity in the lungs remained, which gradually 
has diminished in size, and now, after six years, is barely traceable. 
Many years elapsed before he regained his former health and 
appearance. This case of gangrsena pulmonum is the only one that 
I have seen terminate favorably. 

In the other, n on -traumatic, cases of gangrene of the lungs, the 
disease makes its appearance by a sudden aggravation of the general 
condition, in which the face, in particular, quickly becomes changed, 
assumes a leaden hue, and a distorted Hippocratic fades, and the 
pulse becomes extremely small and rapid. The temperature of the 
skin is not increased ; the putrid odor from the mouth is always 
the most pathognomonic sign, which cannot be attributed to any 
morbid alteration in the mouth. The physical investigation may 
prove barren of results, if the process is central, or there be feebly 
circumscribed dulness, crepitating rales, bronchial breathing, and 
sibilant rales, or when perforation of the lungs occurs, and signs of 
pneumothorax appear. Generally, the sputa are bloody, the cough 
is intense and spasmodic. Colliquative sweats, hectic fever, and 
delirium, soon become superadded, after which death almost in- 
variably closes the scene. 

Treatment. — Where death appears to be inevitable, any rational 
treatment must be doubtful. The recoveries observed hitherto have 
been achieved by a treatment wnth quinine, mineral acid^, acetate of 
lead, chlorine and its preparations, and finally, with creosote. 

(9.) Periodic NocTUEisrAL Cough. — Periodic night-cough is an 
extremely rare and peculiar disease. It is observed in perfectly 
healthy children, but oftener in those with hereditary tuberculosis, 
and usually attacks children from two to ten years of age. 

Throughout the entire day, the child does not cough, sleeps tran- 
quilly in the evening, and, as a rule, wakes up only after midnight, 
crying violently, and coughing. Generally, the cough is continuous 
and dry, not so pai'oxysmal as to give rise to dyspnoea as in whoop- 
ing-cough, but severe enough to prevent sleep for two or three hours 
every night. It is not accompanied by expectoration, and the 
character of the cough is best compared with that of an hysterical 
18 



262 DISEASES OF CHILDREN. 

girl, who sometimes suffers from paroxysms of a purely spasmodic 
cough. This cough recurs every night, not precisely at, but about 
the same hour, every paroxysm lasting an equally long period, 
until finally the child, entirely exhausted, and breathing rapidly, 
falls asleep, to wake no more till morning. Thus it goes on for 
wrecks, and even months, the attacks finally becoming shorter and 
feebler, and ultimately ceasing entirely. The eruption of a tooth of 
the first or second dentition often forms the final act of this enig- 
matical disease. I have met with it but three times ; one child, both 
previously and subsequently to the attack, was perfectly well, but 
the other two were the progeny of tuberculous parents, and subse- 
quently exhibited very distinctly the signs of progressive tubercu- 
losis. Although the cough in the daytime ceases completely, and 
no sibilant rales whatever can be heard over the entire thorax, 
nevertheless, during the whole day, the children are gloomy, morose, 
and become anaemic. They have not a proper appetite, and mostly 
suffer from cold feet. 

Treatment. — The distinct intermission which marks the course of 
the disease seems to indicate a treatment with quinine. But, not- 
withstanding this circumstance, this remedy has proved itself totally 
useless, the cough in most instances recurring, even when large 
doses, from four to six grains, are administered at a time. Small 
doses of narcotics are quite as unsatisfactory. Opium and mor- 
phine, given to produce profound narcotism, do indeed bring about 
an arrest of the malady for one night, but the attending bad effects 
of large doses — loss of appetite, headache, and obstinate constipa- 
tion — are so unpleasant, that I have always been compelled to de- 
sist from a continuous administration of these remedies, before ob- 
taining any permanent result. The inefficacy of quinine and mor- 
phine proclaims with tolerable emphasis that a material alteration — 
to be sought for, perhaps, in a swelling or tuberculosis of the bron- 
chial glands — must be at the bottom of this disease. It is best to 
limit the treatment to a good diet and tonics, fresh air, and uniform 
temperature, with which, according to the experience so far ac- 
quired, the malady has always, although after a very long time, termi- 
nated favorably. 

¥.— PLEURA. 

(1.) Pleurisy {Pleuritis). — Pleurisy may even attack children 
in rde^'O, who then as a rule perish, or sur\dve the delivery but a 
short time. In the new-born child, phlebitis umbilicalis is a frequent 
cause of purulent absorption, and thus also of secondary pleurisy. 



DISEASES OF THE RESPIRATORY ORGANS. 263 

Empyema occurs so rarely in early infancy that the most expe- 
rienced Paediatricars have only been able to report a few solitary in- 
stances. On the other hand, general pleuritic adhesions are often 
found in young children, who, during life, suffered from pulmonary 
affections, particularly from phthisis pulmonalis. In older children 
empyema occurs not infrequently, becomes, when no complications 
are present, tolerably quickly absorbed and leaves behind it no re- 
markable deformity of the thorax. Altogether, pleurisy in the first 
age of childhood may be regarded as an extraordinarily rare affection, 
and as a tolerably infrequent one after the beginning of the second 
dentition. 

Pathological Anatomy. — According to F. Weber, of Kiel, to 
whom we are indebted for most of our knowledge concerning this 
condition, the profuse transudation of bloody serum into the large 
serous sac, and consequently also into the pleural cavities, is to be 
accurately distinguished from the genuine pleurisy of still-born 
children. No flakes of fibrin are ever found in that simple ca- 
daveric transudation, nor has the mother during her pregnancy 
experienced any symptoms referable to that condition. In these 
still-born children, Weber assumes a -purely iiiflamtnatory and a 
dyscrasic pleuritis. 

In purely inflammatory pleurisy of children before birth, the cor- 
responding lung, in most instances, is also affected. The pleurisy is 
unilateral or bilateral, and is seen as a thick or thin, fibrinous, whit- 
ish, transparent layer, which sometimes is easily, and other times 
again with difficulty, pulled off. The serous effusion is here always 
insignificant, yellow, and clear, and entirely different from the cachec- 
tic, never putrid, and never very strongly tinged with blood. 

In dyscrasic pleurisy, both pleural sacs, and, in addition, gen- 
erally also the pericardium and peritonaeum, are simultaneously af- 
fected. The exudations are present in larger quantities than in the 
preceding form, and have a dirty, opaque appearance, and a putrid 
smell. This form occurs only in lying-in hospitals, and at the climax 
of epidemics of puerperal fever, Pysemic pleuritis, occurring as a 
result of umbilical phlebitis, also has the same characters. 

In older children, pleuritic adhesions and layers of false mem- 
brane are very frequently observed ; very seldom, however, large 
effusions. These inflammatory affections of the pleura but very 
rarely occur primarily and in an isolated form, but are always com- 
plicated with disease of the lungs and with tuberculosis. The mor- 
bid formation of false membranes, the displacement of the thoracic 
viscera, and of the diaphragm, are similar to those which take place 
in the adult. 



26i DISEASES OF CHILDREN. 

Symptoms. — Every pleuritis begins with fever. The child be- 
comes restless, sleepless, loses its appetite, and suffers thirst. The 
most distinct sign of fever is always an increase in the temperature 
of the skin over the entire body ; whereas the frequency of the 
pulse, particularly in infants, deserves less consideration on account 
of its great physiological fluctuations. Older children suffer also 
from a chill. 

In young children \\iQ pain can only be elicited by exercising an 
alternate pressure upon various parts of the thorax, or by percussion. 

Pressure or a blow upon a part freshly attacked by pleurisy al- 
ways causes the child to utter a cry or moan of pain. Somewhat 
older children, two or three years of age, when questioned concern- 
ing the site of the pain, point to the prsecordia, though there be no 
signs of disease there. To the statement of children imder five or 
six years old, as to the locality of pain, no value can be attached. 
Generally, it comes on simultaneously with the fever, but hardly 
ever is of long duration, exhibits very distinct remissions, and, after 
four to six days, often disappears entirely, even without any reme- 
dies having been employed. 

In general, it may certainly be said that the fever and the pain 
progress pretty regularly together, still, very frequent exceptions oc- 
cur to this rule. The sudden recurrence of a pain that has been ab- 
sent for several days deserves particular consideration, especially if 
it is attended by fever ; for it then indicates that the pleuritis is not 
simple, but a complicated one, and pulmonary tuberculosis may be 
stated to be the most frequent complication of, or rather cause for the 
{ippearance of such symptoms. The pain also exercises great influ- 
ence ui^on the degree of the dyspnoea, which at first is much more 
aggravated by it than by the mechanical impediment, the effusion. 
As soon as the dulness becomes considerable, the effusion conse- 
quently having become greater, the pain, in most instances, vanishes 
altogether, and in its place the mechanical embarrassment, j^roduced 
by the compression of the lungs, ensues. Why the pain is often con- 
fined to one spot only, notwithstanding the great extent of the pleu- 
risy, is difficult to explain. The most plausible supposition, it seems 
to me, is, that the inflammation, in some part, implicates the neu- 
rilemma of the intercostal nerves, and thus the circumscribed, fixed 
pain, violently aggravated on pressure, is produced. 

The decubitus in young children, who, in general, lie on the 
back, naturally has no great significance ; but older children, at the 



DISEASES OF THE RESPIRATORY ORGANS. 265 

invasion of the pleurisy, as a rule, lie, as long as the pain exists, upon 
one side, but not always upon the one corresponding to the pain. 
This seems to depend upon whether the pain is aggravated more by 
the pressure, or by the acts of respiration. In the first case, they lie 
upon the sound side ; in the second, upon the affected one ; for, 
in this later decubitus, the acts of respiration become smaller in 
a purely mechanical manner, without any special effort on the part 
of the patient. 

The acts of respiration vary in Mjid and nionber according to 
the pain and fever. The more intense these two symptoms are, 
the more rapid and superficially do the children breathe. On the 
other hand, the effusion, after the acute process has ceased, is sel- 
dom so bulky as to keep uj) a continuous acceleration of the respi- 
ration. In form, the accelerated breathing is that of the expiratory, 
i. e., the accent lies upon the expiratory sound. No actual dyspnoea 
is present, but the respirations are frequent and superficial, in order 
that the deeper and painful ones may be avoided. For the same 
reason the movements of the alaa nasi are also less marked than in 
parenchymatous disease of the lungs, for example, in pneumonia, 
or advanced tuberculosis. 

By inspection it is not possible to ascertain upon which side the 
pleurisy is situated, so long as there is only a pleuritic membranous 
exudation, and no bulky liquid effusion. But, when the latter has 
formed, the intercostal spaces become obliterated and bulge out- 
ward, and all those ribs which are separated from the corresponding 
part of the lung by the fluid effusion remain stationary. Then, 
mensuration of both thoracic halves also furnishes a larger circum- 
ference for the affected side. In lean children, a sinking of the 
liver, in right unilateral effusions, is seen, and, in left unilateral 
effusions, a displacement of the heart toward the xyphoid cartilage, 
and even beyond it. 

Pleuritic effusions may very readily and accurately be diagnos- 
ticated by palpation of the vocal fremitus, and, in children, this 
method of examination is of the greatest value, as it can be prac- 
tised in restless, crying children. So far as the fluid exudation 
reaches, no, or but a feeble, fremitus of the voice is to be felt, while 
it is felt at the same time stronger over the rest of the thorax. 
Friction-sounds are extremely rai'ely met with in children at the 
beginning of pleurisy. They are somewhat more frequently heard 
in an empyema undergoing absorption, and are generally found at 



266 DISEASES OF CHILDREN. 

the place of transition from dull percussion to sonorous sound. 
Indeed, it is even possible to detect tbem by palpation alone, but, 
by palpation, it is very easy for one to be deceived by simultane- 
ously-occurring sibilant rales. In quiet, sensible children, this physi- 
cal method of examination may readily be completed by auscultation. 
At the commencement of a pleurisy, either friction-sound or normal 
vesicular breathing is heard, provided the lungs have not been pre- 
viously affected. In most cases nothing whatever is to be heard 
after the fluid effusion has separated the lung from the ribs ; some- 
times, however, very unexpectedly, and without our having been 
able until then to obtain a special explanation, well-marked bron- 
chial respiration is beard, but which lasts only for a few days, and 
then totally disappears. But when the exudation becomes so large 
in quantity that the lung of the affected side is wholly compressed 
and pushed backward into a solid compact mass, not puerile, but 
bronchial breathing will be heard upon the dorsum of the thorax as 
far as the airless lung extends. As the absorption of the empyema 
progresses, the lung dilates, the bronchial breathing disappears, 
sibilant rales often come on, or the normal vesicular breathing is 
again heard. 

Percussion supplies positive results in very extensive fluid effu- 
sions only ; compact pleuritic exudations, and, still less, simple 
pleuritic adhesions, effect no alteration whatever in the percussion- 
sound. But, when pleuritic effusions have actually taken place, we 
have a far more distinct dulness than in solidification of the pul- 
monary tissue ; we get a completely flat sound (the so-called thigh 
or wall sound). On the margin of the dulness, a tympanitic sound 
is invariably heard, which extends itself for some distance into the 
sonorous sound. 

If at any time a large quantity of purulent effusion had accumu- 
lated in one of the pleural sacs, and subsequently become absorbed, 
a condition that is almost exclusively met with in children several 
years old appears. The behavior of the pleura after the absorption 
of the empyemic fluid, so strikingly observed in adults, soon becomes 
manifest. On the affected side the shoulder is depressed, the nates 
somewhat elevated, the entire pectoral half flattened and contracted, 
strongest between the fifth and eighth ribs, and the spinal column 
suffers a lateral curving, the concavity of which is directed toward 
the affected, the convexity toward the healthy side. A compensa- 
tory curvature of the lumbar vertebrae is, of course, also present. 
As the patients progress in recovery, and become invigorated, these 



DISEASES OF THE EESPIEATORY ORGANS. 267 

distortions disappear almost completely in a few years, which, is 
very much facilitated by an appropriate gymnastic training. 

Spontaneous perforation of the thoracic walls, and evacuation of 
its contents outwardly, occur oftener in empyema of children than 
in that of adults. An erysipelatous erythema, attended by fever 
and lancinating pains, appeal's on some part of the thorax, most 
frequently on its anterior part, under the nipple ; the corresponding 
intercostal space bulges more and more, fluctuation at length be- 
comes more distinct, and, finally, there forms a circumscribed oval 
swelling, which bursts spontaneously, or may be opened with a 
lancet without any danger. At first a large quantity of pus is evac- 
uated, but soon the abscess contracts, and is converted into an 
oblique, angular, fistulous passage, which frequently closes, but 
after a while is again attacked by inflammation, and breaks open 
anew. Such a fistulous canal will remain open for months, and even 
years, according to the condition and distensibility of the corre- 
sponding lung, and ultimately closes with a radiating, contracted, 
deep-pitted cicatrix. Caries of the ribs, notwithstanding the long 
duration of the process, scarcely ever occurs. 

The complications of pleuritis are numerous. First of all, the 
various general diseases, in the course of which pleurisy may become 
developed, are to be mentioned. Thus, it occurs in scarlatina, 
measles, small-pox, typhus fever, pygemia, and scorbutus. The fre- 
quency of these complications varies according to particular epi- 
demics. Pleurisy is most unfavorable and dangerous when it super- 
venes early on a general disease, while that occurring during conva- 
lescence comparatively often takes a favorable course. Pleurisy, as a 
result of i^ysemia and scorbutus, is, naturally and unexceptionally, 
fatal. 

Pleuritis very often is a secondary disease of tuberculosis and 
pneumonia. In fact, there is no peripheral morbid alteration of the 
pulmonary parenchyma in which the pleura does not participate. 
Although the ordinary form is that of simple adhesions, or, at the 
most, of narrow pleuritic membranes, still, quite extensive effusions 
not infrequently occur, especially in tuberculous children. They are 
scarcely ever sirajDly purulent, but metamorphose even into the 
tuberculous. The entire pleura, surrounding the exudation, is con- 
verted into a yellow, granular, tuberculous membrane, and no ab- 
sorption of any such exudation has yet been observed. Perforation 
of a tubercular lung into the pleural cavity and pyo-pneumothorax, 
as a result of the more acute course of tubercles in children, rarely 
occurs. 

The course and termination are variable. Acute primary pleu- 



288 DISEASES OF CHILDKEX. 

risy, as it sometimes attacks healthy older children, is, notwith- 
standing the extensive effusion filling up the entire pleural sacs up 
to the apices of the lungs, not a dangerous disease. After one or 
two months, absorption begins, and, if the children are in other 
respects healthy, is completed in three months. Even the hahitus 
of the absorbed empyema that remains behind is tolerably well 
outgrown in the course of a few years. Acute secondary pleurisy, 
as it is observed in the course of acute exanthemata, of typhus 
fever, and of tuberculosiSj is incomparably more dangerous, and 
pysemic pleuritis of the new-born child is unexceptionally fatal. So 
also is pyo-pneumothorax, after the bursting of a tuberculous cavity ; 
but this, on the whole, is a very rare condition. 

Chi-onic pleuritidis, thin layers of false merabi-anes or simple ad- 
hesions, such as accompany every affection of the lungs, are apt to 
undergo no or extremely slow absorption. The morbid alteration 
of the lungs becomes so prominent here, that the pleuritic phe- 
nomena very seldom attract any attention. Sacculated empyemas, 
which in the adult may exist for ten and twenty years, do not occur 
in children, in whom the more rapid development is always attended 
by a comparatively quicker absorption. 

Treatment. — Many words need not be wasted in describing the 
therapeutics of secondary pyasmic pleurisy of the new-born child, for 
it is a fatal affection under all circumstances. Primary pleurisy of 
older children, with rapid effusion at first, is to be treated moderately 
antiphlogistically. There is no remedy by which the augmentation 
of the effusion can be certainly arrested ; it is not possible to accom- 
plish this even by the largest abstractions of blood. This remedy, 
consequently, is not admissible ; still, it cannot be denied that in older 
children, over five years of age, the severity of a pleuritic pain may be 
very much alleviated by a few leeches. In infants, the moist girdle 
alone, already described in the section on pneumonia, but which 
has to encircle the whole thorax for from four to six days, suffices to 
mitigate the pain. 

The internal treatment, so long as the fever and pain are very 
considerable, is best founded upon the administration of small doses 
of calomel, to which small quantities of oj^ium may very properly be 
added — \ to ^ grain of calomel, and yo to i grain of opium, may be 
given daily to children, three to six years old. Diarrhoea should 
never be allowed to run very long. If the pleuritic effusion has al- 
ready ceased to increase, and has become stationary, the fever will 
subside too, and then there is no indication for the above-named 
remedies. The question that comes up for consideration is about 



DISEASES OF THE RESPIRATORY ORGANS. 269 

the removal of the effusion in as short a time as possible. For this 
purpose inunctions of blue and iodine ointments are resorted to. 
Internally the various diuretics are recommended. 

The alkaline diuretics, nitrate and acetate of potassa, are not adapt- 
ed to children, on account of their bad taste and drastic effect. On 
the other hand, small doses of digitalis, gtt. vj — xij pro die of the 
tincture, in a two or three ounce vehicle, are very well borne, but are 
to be discontinued as soon as slowness of the pulse ensues, and re- 
peated when that passes off. But rooh * jxm.iperi is tolerated long- 
est and best of all the diuretics, of which one or two teaspoonfuls 
daily may be given to the child for months. The effects of the diu- 
retics, on the whole, should not be over-estimated, for it has often 
already been observed that such simple pleuritic effusions, under 
favorable circumstances, have in a few weeks disappeared entirely, 
although no internal treatment had been resorted to. Proper nutri- 
tion and good air are the main factors for the success of a rapid ab- 
sorption. Hospital air acts extremely injuriously upon the absorp- 
tion of an empyema, and such patients are therefore to be kept as 
far from the hospitals as possible. In older children the operation 
of paracentesis thoracis has often been performed with success. I, 
however, have never yet met with a case where it was absolutely 
called for, and for that reason have never performed it. 

Till now the use of the explorative trocar alone has been sufficient, 
and with this instrument I have succeeded in drawing off, at one 
time, twelve ounces of effusion. A valvular puncture made into 
the thorax with the trocar is perfectly harmless ; it maybe repeated 
as often as required, and this treatment is more rational than large 
incisions followed by washing out the pleural cavity, which is liable 
to cause pysemia. It is useless to draw off all the effusion at once 
from the pleural cavity, because the lung is bound down by a 
layer of false membrane, which does not permit it to expand quick- 
ly enough to fill the cavity ; hence it is better to draw off only a 
portion of the pleural effusion, and allow it to expand gradually, 
even if at the risk of requiring a second tapping. 

Twice I saw, in healthy, robust, well-developed children, a swell- 
ing arising under the mamma, one of which opened spontaneously, 
the other was opened with the lancet. In both instances a large 
quantity of pus escaped at first, and the lungs dilated correspond- 
ingly. But the fistula which remained healed only after the lapse 
of years, and several times broke out anew. 

(2.) Htdrothoeax. — In nurslings, serous effusions into the pleural 

* See note on page 191. 



270 DISEASES OF CHILDREN. 

sacs occur very infrequently ; in older children, however, they are more 
frequently seen as the effects of certain diseased conditions. The fluid 
poured out is purely serous, yellow, albuminous, and the salts it con- 
tains exhibit the same quantitative proportions as those of the serum 
of the blood. On the pleura itself no morbid alterations are to be de- 
tected, if no pulmonary disease with mild pleioritis have preceded it. 

Etiology. — Some authors still assume that a primar}', essential 
hydrothorax may occur, but that is extremely problematical, for some 
preceding diseases, in certain instances, are readily overlooked. Nephri- 
tis, the result of scarlatina, undoubtedly furnishes the most frequent 
cause ; next follows the intermittent-fever cachexia, and finally, as 
the rarest cause, an acquired disease of the heart is to be mentioned. 
The rest of the cachexiiE, through which, in the adult, hydrothorax 
may also be engendered, such as hepatic cirrhosis, chronic Bright's 
disease, carcinoma, paralysis, etc., scarcely ever occur in children. 

Symptoms. — Hydrothorax after scarlatina appears several days 
after anasarca has appeared, but by this we do not intend to say that 
it must absolutely follow in this manner. Anasarca is regularly 
ushered in by febrile phenomena, which become aggravated when 
serous effusions into the pleural and peritoneal cavities are superadded. 
The formation of the diagnosis in that case is much facilitated by the 
existence of the anasarca. 

Hydrothorax, as a result of intermittent-fever cachexia, sometimes 
occurs with, sometimes without, fever. Generall}-, however, anasarca 
is also present here, at least of the lower extremities. The grayish- 
yellow color of the face, the extreme antemia of the mucous mem- 
branes, and the invariably present splenic enlargement, are such 
prominent signs as to preclude the possibility of mistaking the inter- 
mittent cachexia for any other. 

Hydrothorax in consequence of disease of the heart is the rarest 
form, because in children endocarditis occurs very infrequently, and 
generally quickly terminates fatally, and because congenital cardiac 
malformations terminate usually too early to produce dropsical effu- 
sions. 

Hydrothorax, in contradistinction to pleurisy, is much oftener ob- 
served on both sides than on one side only ; still, the quantity of the 
effusion is seldom alike on both sides. The pain in the side, so con- 
stant and persistent in pleurisy, is totally absent in hydrothorax. In 
a marked example of hydrothorax, the dulness is complete, and its 
boundaries may be changed readily by varying the position. Children, 
however, do not willingly submit to this kind of manipulation. The 
fluid is so thin and copious, that it quickly changes its place in ac- 
cordance with the laws of gravity. Friction-sounds are never felt nor 



DISEASES OF THE NERVOUS SYSTEM. 271 

neard, but the external form of the thorax becomes altered as strik- 
ingly as, and perhaps still more so than, in empyema. Dilatation and 
bulging of the intercostal spaces, immobility of the part of the thorax 
"with, which the serum is in contact, and alterations of the position of 
the heart and liver, occur here in the most striking manner. 

As hydrothorax in most instances is bilateral, the dyspnoea, there- 
fore, increases rapidly ; soon orthopnoea, cyanosis, and oedema of the 
lungs supervene, whereupon death quickly ensues. The secretion of 
urine in most instances is very much diminished ; the bowels may be 
torpid, or, as is frequently the case, a derivative attempt may have 
been made by the alimentary canal, giving rise to diarrhoea. 

The pulse at first is much accelerated, but in moderate dyspnoea 
may soon return to its normal condition. 

The prognosis may be set down as most unfavorable after scar- 
latina, not very favorable after intermittent fever, and decidedly 
unfavorable, if not positively hopeless, after cardiac disease. 

Treatment. — A debilitating, antiphlogistic treatment is never in- 
dicated here, although in the first days of the illness distinct febrile 
phenomena may have been present. The subjects always become so 
exhausted by their preceding sufferings, that it seems absolutely neces- 
sary to pay the utmost attention to the nutrition. Nourishing broths, 
with yolk of egg and milk, should therefore be allowed them, and as 
much as they will consume ; and an attempt is to be made by mild 
diuretics, such as will not disturb the digestion nor cause diarrhoea, 
to stimulate the kidneys and to promote the excretion of the urine. 
In this respect a few drops of the tincture of digitalis, with roob 
Jmiijjeri in large doses, as I have often stated, are the most appro- 
priate remedies. In the after-treatment, quinine and iron are most 
to be relied on. 



CHAPTER V. 

DISEASES OF THE NERVOUS SYSTEM. 

A.— BRAIN. 

(1.) Htdrocephaltjs Acutus Internus. Synonyma. — Meningeal 
tuberculosis, morbus cerebralis Whyttii, hydrophlogosis ventricu- 
lorum cerebri [I/obstein), febris hydrocephalica. Entero-cephalopyra 
{J^isenman7i). 

The pathology of hydrocephalus consists in a miliary tuberculosis 
of the arachnoid membrane, especially at the base of the brain — in an 



272 DISEASES OF CHILDREN. 

intense aufmientation of the normal fluid contents of the cerebral 
ventricles, and in a softening of the parts of the brain entering into 
the formation of the cerebral cavities. Tuberciilosis of the meninges 
is generally stated to be the exciting cause, and an acute internal 
hydrocephalus, not tubercular, is also spoken of. I have never yet 
met with this latter kind of acute dropsy of the head ; but of the for- 
mer, on the contrary, I have dissected more than fifty cases, and the 
majority of them I also observed during hfe. 

Pathological Anatomy. — In these autopsies, the dissection of the 
skioll must be performed with the utmost caution. If the large 
fontanel is not yet closed, it will be seen to bulge out enormously, 
and often a decided fluctuation may be detected over it. The skull 
should be sa^vn very slowly, and the movements of the saw should be 
short, especially toward the close of the operation, in order that the 
brain, which is often very soft, may not be injured, and the contents 
of the ventricles be lost before they are closely inspected. If the dura 
mater, at certain places still adheres to the bone, it will be very 
difficult to remove the calvarium, conjointly with the dense dura 
mater, without injuring the brain. In these rare cases it is advisable, 
after the skull has been saAvn through, not alone to sever the dxira 
mater all around, but also the brain, and then to remove the calva- 
rium, dura mater, and the whole portion of the cerebral substance 
lying above the incision, en masse, by the aid of a brain-knife or spatu- 
la. It is true that, by so doing, the ventricle is opened and its watery 
contents escape, but then we have the advantage of being able to 
examine more accurately the base of the brain, and we thereby also 
spare the rest of the generally soft, friable portion of the organ. 

After the calvarium and dura mater have been removed, the brain 
to a certain extent bulges out over the edges of the divided skull, 
the pia mater and arachnoid will be found to be very tense, the arach- 
noid membrane upon the convex part of the brain dry, and the convo- 
lutions obliterated ; it is, therefore, plain that the cerebral substance has 
been firmly compressed from within outward against the bones of the 
head. That the injection of the meninges in the cadaver had no con- 
nection with the injection of the meninges during life now becomes suffi- 
cientlv evident, and there is nothing pecuUar in the circumstance that 
in acute hydrocephalus they are sometimes found dark red, and then 
again very pale and anagmic. If it is desired to institute a chemical 
examination of the hydrocephalic fluid, which is very instructive, 
the ventricle should be punctured xery cautiously with a trocar and 
only the fluid thus evacuated should be examined ; for, if the whole 
quantity of liquid that escapes on opening the ventricle be collected, 
it will always be found to be a mixture of blood and cerebral dropsi- 



DISEASES OF THE NERVOUS SYSTEM. 273 

cal effusion, wliich is entirely unfit for tlie purpose of sucli a chemical 
examination. 

The chemical analysis of a pure hydrocephalic effusion furnishes 
extremely peculiar results, to which O. Schmidt first directed the 
attention of the profession. The chemical reaction of this fluid is 
always distinctly alkahne ; it is almost as clear as water, and contains 
only traces of albumen, for, on boiling it and testing it with acid, it 
is rendered hardly perceptibly turbid, and precipitates no large dense 
flakes of albumen. The proportion of salts in the eifusion is also a 
peculiarity that deserves to be mentioned. While the transudation 
collected from the peripheral meninges, pia mater, and arachnoid, 
contains the salts exactly in the same proportions as the exhalations 
from other serous membranes — to wit, in the proportions of the serum 
of the blood — the transudation of the choroid plexus contains more com- 
binations of potassium and of phosphorus, so that the proportion of 
potassa to soda and that of the phosphates to the chlorides, approxi- 
mates nearer the salts as they occur in the blood-corpuscles. While 
the salts of the meningeal transudation, according to C Schinidt, 
contain 2.8 per cent, of potassa and 40 per cent, of soda, in the salts of 
the fluid from hydrocephalus internus nearly 17.8 j)er cent, of potassa 
and only 27.2 per cent, of soda are found. We have therefore in this 
case no mere filtration of the serum of the blood, but a peculiar secre- 
tion, in the formation of which the salts of the corpuscles of the blood 
seem to participate. 

The walls of the ventricles are more or less softened, and their 
ependyma (lining membrane) is destroyed. The distention of the 
lateral ventricles is often of such an extent as to rupture the septum 
ventriculorum, and the two cavities then directly communicate with 
each other. In extreme cases this softening is also found in the optic 
thalami, in the corpus callosum, and in the corpus striatum, the upper 
svirface of which appears eroded, shreddy, flocculent, and uneven. The 
choroid plexus is bloodless, very pale, and not superabundantly filled 
with blood, as is unaccountably stated in most of the late French 
works. This bloodlessness is very natural, for the enormously accu- 
mulated fluid must very greatly impede the filling of this arterial 
plexus. The anaemia, in connection with the general dilatation of the 
ventricles, is the best criterion by which to judge of the extent of the 
hydrocephalus, if accidentally or incautiously the liquid, on opening 
the skull, has been allowed to escape prematurely. 

This part of the examination having been concluded, we then turn 
our attention to the base of the brain. Here a whitish or greenish- 
yellow exudation of a peculiar gelatinous nature is seen to have been 
deposited in and between the pia mater and the arachnoid membrane. 



274 DISEASES OF CHILDREN. 

By tkis exudation the sulci of the brain have luecome agglutinated 
and plastered over, and the depressions at the base of the brain, espe- 
cially those corresponding to the cella turcica, are evenly filled out 
and obliterated. The exudation is most abundantly accumulated 
Vi'ithin the bilateral lulus cerebri, from the chiasma opticum to the 
pons, over this on to the medulla oblongata, and spreads upward, 
especially into the fossa Sylvii, and the longitudinal fissure of the 
cerebrum. Here, in the fossa Sylvii, along the artery and vein, the 
tuberculous character of this exudation is most distinctly recognized, 
for here, in particular, a countless number of fine white granules is 
seen, which, on microscopic examination, prove to be miliary tuber- 
cles. They consist entirely of an amorphous granular mass of detri- 
tus ; the fibres of connective tissue seen here and there do not belong 
to the miliary tubercles, but to the pia mater, in which the tubercles 
are embedded. Miliary tubercles, in addition to being found in the 
fossa Sylvii, are also seen to have been de^Dosited over nearly the en- 
tire base of the brain, especially along the course of the vessels. 

In regard to the other organs, it is always observed in this afi'ec- 
tion that an older, larger, yellow tubercle exists somewhere in the 
body, most frequently, in fact, in the bronchial glands ; next in the 
lungs, then in the brain itself, and sometimes also in a bone. The 
connection between acute hydrocephalus and softening of the stomach, 
mentioned in some text-books, in reality does not exist, as has already 
been clearly shown in our remarks on softening of the stomach, page 
149. 

Symptoms, — The disease most frequently attacks children from 
two to seven years of age. The youngest child in M^hom meningeal 
tuberculosis has been observed was three months old ; in older chil- 
dren and adults the miliary tuberculosis localizes itself much oftenei 
in the lungs than in the meninges. 

]\Iany divisions into stages have been proposed with a view of 
facilitating the study of this disease. Thus (1) a stage of conges- 
tion ; (2) of inflammation ; and (3) of exudation, have been assumed. 
Mouchut speaks of a stadium prodromorum, invasionis, and con\ail- 
sionis, but, strictly speaking, no stadial division, based upon patho- 
logical anatomy, can be assumed ; symptomatically, one into (1) a 
stage of u-ritation and (2) of paralysis may be practicable. In the 
first stage, the prodromata and the symptoms of hydrocephalus that 
have already appeared may be recognized. 

The prodromata are of an extremely peculiar and variable form. 
Although it certainly cannot be denied that the study of these has been 
extended somewhat too far, and that much that is irrelevant has been 
Added to them, still their existence cannot be ignored. Above all, 



DISEASES OF THE NERVOUS SYSTEM. 275 

it is necessary to determine whether the acute hydrocephalus has de- 
veloped itself in a child, who, for a long time previously, has had dis- 
tinct signs of tuberculosis — usually pulmonary — or whether these 
signs have hitherto been absent, and the disease has developed itself 
in an apparently perfectly healthy child. It is, indeed, asserted by 
some hospital physicians that the premonitory signs may be totally 
absent, and the symptoms of developed inflammatory hydrocephalus 
may come on at once ; in private practice, however, such cases have 
not been observed. Here, for several days, sometimes even for many 
weeks, some tolerably constant prodromata are always noticed, which 
only slowly become aggravated, till we finally have the disease before 
us developed in its most dangerous form. 

This stadium prodromorum usually lasts two or three weeks, 
though cases are also met with where the children present these signs 
for several months. The most constant of these symptoms is a slow- 
ly progressive emaciation, which, in a most remarkable manner, en- 
tirely spares the face, so that the child, when dressed, presents noth- 
ing unusual in its appearance. But observing mothers and nurses 
invariably notice it, and the prominence of the ribs, in particular, ex- 
cites their apprehension. A slight paUor of the countenance, and a 
peculiar lustre of the eyes, soon become associated with this condition. 
The patient now loses all healthy cheerfulness and liveliness habitual 
to it. It sleeps more than usual, soon forsakes its amusements, be- 
comes morose and timid before others, and cries for the slightest cause. 
It is also very remarkable that it does not attempt any of its former 
httle braveries, for instance, the climbing upon chairs, the opening 
of difficult door-latches. Even the looking out of a grated window 
intimidates it, and, when requested to perform these feats, it wiU 
sternly refuse. Boys who formerly would put up with nothing from 
their comrades, but were always ready to fight and defend themselves, 
now cowardly slink away crying. Other children, again, become re- 
markably affectionate, constantly embracing and clinging to their 
parents, and, when left alone, are inconsolable. 

In older children, who have already commenced study, the tutor 
notices an unusual absent-mindedness and indifference ; the learning 
by heart is more difficult than before, and what is finally acquired is 
uttered in a stuttering manner. The children sleep very much, and 
often fall asleep in the daytime. Their night-sleep, however, is 
not sound, is repeatedly broken by unpleasant dreams ; they toss 
about in bed, and frequently break out into apprehensive exclama- 
tions. The appetite is gone ; often there are capricious longings for 
stimulating food, of which, however, but little is consumed. The 
thirst is not augmented, the secretion of urine but slightly diminished ; 



2Y6 DISEASES OF CHILDREN. 

the urine is often so rich in urates that they settle on the bottom of 
the vessel, and form what has been called the brick-dust sediment. 
The bowels are usually torpid, particularly in older children ; but, 
should a diarrhoea exist, it should not, by any means, be interpreted 
as incompatible with the existence of acute hydrocephalus. Particu- 
larly in infants, who are still laboring under the first dentition, it often 
happens that the ordinary diarrhoea of dentition continues as in the 
normal state, and an acute hydrocephalus has nevertheless been in- 
trenching' itself. Headache is scarcely ever complained of, even by 
older children ; vertigo and an unsteadiness on walking are much oftener 
observed. Some time ago, a boy four years old, who displayed sev- 
eral premonitory S3^mptoms of acute hydrocephalus, was brought to 
me. On walking upon the even floor, he always lifted up his feet 
very high, as if mounting a step. In the course of a few days the 
disease developed itself more markedly, and the autopsy subsequently 
confirmed the diagnosis. These children tolerably often complain of 
abdominal pains, which are distinctly aggravated on pressure. Fever 
is usually not present ; still, what has been said of diarrhoea is also 
applicable to this symptom, the presence of fever is no reason what- 
ever for excluding the possibility of a commencing hydrocephalus. 

The symptoms just described, conjointly or singly, now become 
more and more aggravated ; the children betake themselves to bed, 
and hereupon the signs of commencing efi"usion, likewise those of 
cerebral irritation, develop tliemselves. 

Difi"erent are the circumstances when children with marked pid- 
monary tuberculosis in addition acquire meningeal tuberculosis and 
hydrocephalus. In this case, the symptoms of the preexisting phthisis 
pulmonalis, such as hectic fever, excessive Aveakness, severe bronchitis, 
etc., are naturally so conspicuous that the prodromata, delineated 
above, are scarcely noticeable. Then, the disease begins directly with 
the symptoms of commencing effusion, and the irritation produced by 
that process. 

The most characteristic symptoms of the stage of irritation are : 
vomiting, constipation, slow pulse, unrh3^thmical respiration, increased 
temperature of the skin, retracted abdomen, headache, extreme ex- 
citability alternating with somnolence, diminution of the intelligence, 
and the various kinds of motor disturbances. 

The preponderating symptoms of the stage of paralysis are : great 
acceleration of the pulse, profound coma, and paralysis of the volun- 
tary muscles. In order not to break off constantly in the description 
of the individual symptoms, and as the transition of one stage into the 
other can b}'^ no means be so accurately defined, as some of the text- 
books declare, this stadial diA^sion will, therefore, be dispensed with 



DISEASES OF THE NERVOUS SYSTEM. 277 

in the follomng delineation, and each symptom will be followed at 
once to its fatal end. 

As regards the disturbances of the digestion, vomiting must rank 
first. It is a remarkably constant symptom, and usually comes on so early 
in the disease that the diagnosis may be established by it much earlier, 
and with greater precision than by any other symptom. The duration 
of the vomiting, however, is very variable. Some children vomit for 
only one day, others several days, and only a part of the food partaken 
of. Others, on the contrary, vomit incessantly from the commence- 
ment of the disease almost till death, and there is no article of food 
which is not vomited almost as soon as it is taken. A peculiar feature 
about this vomiting is, that it makes no remission, never recurring, 
after it has once ceased for twenty-four hours. The manner in which 
the children vomit is of the utmost importance in the formation of the 
diagnosis. While children who suffer from an indigestion are afflicted, 
for a long time before the actual vomiting, with nausea, eructations, 
retchings, and cold sweats, hydrocephalic children vomit without any 
such preparations, just as if they had taken a mouthful of water and 
then simply spat it out again. Tlie act of vomiting is facilitated by 
setting the children upright, or by laying them on the side. It is 
arrested so long as the stomach remains entirely empty ; when liquids, 
and, still more so, compact nutriments are introduced, they are in- 
stantly ejected without any apparent distress or difficulty. Very sel- 
dom is the matter vomited mixed with bile, a circumstance that is 
readily explained by the slight antiperistaltic action of the stomach. 
As the physician seldom personally witnesses the act of vomiting, 
and, consequently, has to rely entirely upon a verbal description of it, 
he should accurately question the relatives, and make them understand 
that they are carefully and minutely to observe the manner of vomit- 
ing — whether it is easy or difficult, with or without retching, 

A second almost equally as constant a symptom is constipation^ 
from which at least three-fourths of all the hydrocephalic children 
suflFer. The intestinal secretions are so diminished that even the more 
powerful drastic cathartics have no effect, even when they are not 
vomited, which very often occurs. Calomel, so much in vogue in 
other forms of constipation in children, is almost entirely inert in this 
one. This constipation does not continue till death ; latterly, thin 
colliquative stools are voided, no matter whether aperients have been 
emploved or not. Even profuse diarrhoeas, the effects of intestinal 
tuberculosis, may cease in commencing hydrocephalus, but the stools 
which subsequently follow are again thin, and have the well-known 
putrid odor. As a rule, constipation is less constantly observed than 
vomiting, for instances not very infrequently occur in which regular 
19 



278 DISEASES OF OniLDREN. 

stools take place daily from the invasion till the end of the disease. The 
material diminution of their quantity is very natural, and is to be ex- 
plained by the diminished consumption of nutriments. The appetite 
is gone, and the food that is laboriously administered is vomited, and 
it is, therefore, very easy to comprehend how a constipation of several 
days' duration may occur, and in which the abdomen nevertheless be- 
comes more and more retracted, and no fecal matter passes through 
the intestinal canal. 

The rest of the alterations of the digestive apparatus are less 
pathognomonic. The thirst never becomes so intense as in other 
acute febrile conditions, for example, typhus fever, or the acute exan- 
themata, and the secretion of urine is correspondingly always very much 
diminished. This absence of thirst is, in fact, a natural result of the 
slightly-increased temperature of the skin, and the inconsiderable 
acceleration of the pulse, and of the disturbed innervation of the 
stomach. The urine is very concentrated, rich in urates, uric acid, 
coloring matter, and salts, and therefore deposits in the bladder, or 
immediately after it is voided, a thick sediment. Toward the end of 
the disease, the child often passes no water for twenty-four hours, 
or even more, and yet the bladder does not become distended, show- 
ing the existence of a paralysis of the nerves governing this secretion. 
The urine that is finally discharged, or drawn off by the catheter, is 
turbid, has a pungent odor, and an ammoniacal reaction. Albumen, 
so far as I am aware, is not found in it. 

The appetite is seldom as completely absent as in the diseases just 
alluded to ; though it is true that there is no desire for food, still it is 
almost always possible, without any great difficulty, to administer 
milk or beef-broth to such patients, and this is all the more surprising, 
as vomiting almost invariably follows. 

In this stadium, the tongvie is always moist, more or less coated 
with a white fur, and furnishes nothing characteristic. The tongue 
remains moist in almost all infantile diseases, which is due to the cii- 
cumstances that the mucous secretion of the mouth is very profuse at 
this age, and that children have the good habit of sleeping with the 
mouth shut. Tlie gums are likewise always moist, but on these, too, 
the white fur that appears in most of the diseases is also seen. 

The febrile phenomena in hydrocephalus are never of high grade. 
In miliary tuberculosis, which develops itself entirely in the pia mater, 
fever can hardly be said to ever occur ; but if, on the contrary, the 
miliary tuberculosis involves other organs also, especially the lungs, 
or the peritonaeum and pericardium, as pungent a heat of the skin ap- 
pears as is commonly met with at the eruption of an acute exanthema. 
The temperature of the head, particularly the forehead, is, in all in- 



DISEASES OF THE NERVOUS SYSTEM. 279 

stances, decidedly elevated, and remains so to the end, wMle the feet 
are very prone to become cold. 

In general, the temperature of the skin stands in exact relation to 
the rapidity of the pulse, but the forehead always remains hot, even 
when the pulse becomes ever so slow. 

The condition of the pulse has always been regarded as of 
great importance in acute hydrocephalus, and there is, in fact, no 
disease in which it deserves so much attention as in the one under 
consideration. In the incipiency of the malady, the frequency of the 
pulse is due more to the miliary tuberculosis that has developed itself 
in the other organs than to that of the meninges. When the miliary 
tuberculosis is very extensive, and in course of development in the 
rest of the organs, the consequent acceleration of the pulse will coun- 
teract the retardation actually caused by the cerebral affection, and 
may continue for many days, till finally the slow hydrocephalic pulse 
comes on. If, on the contrary, the meningeal tuberculosis occurs, 
the retarded pulse soon manifests itself, and is readily recognized by 
the lessened frequency and modified quality of its beats. Whatever 
may be the explanation, it is a fact that the pulse, at the commence- 
ment of acute hydrocephalus, is often accelerated, but that in other 
cases it also becomes slower and slower from the first day of the dis- 
ease on. In the majority of cases, it is at first slightly accelerated, 
and becomes retarded in a few days. As the watery effusion in the 
cerebral cavities becomes augmented, the number of the beats sinks 
down to between forty and sixty ; usually, however, the pulse does 
not remain stationary upon any definite number, but changes from 
hour to hour, so that, in the course of twenty-four hours, it may be 
forty, then sixty, and then, again, eighty per minute. These varying 
conditions of the pulse are differently explained by different clinical 
observers. Whatever view they take, I have often convinced myself 
of the correctness of the fact. In most cases qualitative changes 
of the pulse also occur, a strong throb follows several small ones, 
or vice versa / also distinct but not regularly-recurring intermissions 
take place, and sometimes the pulse assumes a peculiar vibrating 
character, imparting to the finger a sensation as if it rested upon a 
vibrating string. This character disappears as soon as the finger 
presses a little more firmly upon the artery, and an easy, cautious 
touch is, therefore, necessary for this examination. 

One to three days before death, the pulse again becomes rapid, 
and indeed so rapid that it is hardly possible to count it. It may 
reach 180 to 200 in the minute. Wlien this continually-augmenting 
frequency of the pulse supervenes upon the above-described retarda- 
tion, with its accompanying alteration of quality, a speedy end may 



280 DISEASES OF CHILDREN. 

be prognosticated with the utmost certainty, for Ihis great accelera- 
tion is to be interpreted as indicating commencing paralysis of the 
pneumogastric nerve. 

The alterations of the respiration are also of great importance. 
At the invasion of the disease, the breathing goes on normally, except 
in those cases Avhere the miliary tuberculosis in the lungs has made 
great progress, and the fever is intense. Then, of course, the 
respiration is very much accelerated, and this acceleration is due as 
much to the local disturbances as to the fever, with its implication 
and depression of the organism. But as soon as the symptoms of 
exudation have become more prominent, then they are also infallibly 
manifest by the respiration. It, for example, becomes much slower 
and completely unrhythmical. In one minute the child respires fifteen 
times, in the next thirty, and in another twenty. At one time the 
respirations are superficial, and occur with a barely perceptible dilata- 
tion of the thorax, and without any audible sound ; then, again, they 
are deep and sighing. This latter kind of respiration is so constantly 
observed, that these have been called hydrocephalic sighs. This re- 
tarded and unrhythmical respiration takes place in all cases, even in 
those where advanced pulmonary tuberculosis gives rise to marked 
acceleration of the acts of respiration. Occasionally the breathing is 
arrested for ten seconds and more ; and the next gasp, that is waited 
for by the parents with anxiety, occurs as a deep, long sigh ; and, im- 
mediately upon that, several very normal, tranquil inspirations follow. 
This form of respiration is now designated as the Cheyne-Stokes 
breathing, and has been observed in other diseases accompanied by 
disturbances of the circulation and oedema of the brain. If the pulse, 
shortly before death, has assumed that extraordinary rapidity already 
described, the respiration also will become more rapid again — about 
as rapid, but not as rhythmical, as in the normal condition, and by 
no means in exact proportion to the extreme frequency of the pulse. 

The physical examination of the lungs furnishes either entirely 
negative results, or in some cases it reveals the presence of pulmonary 
tuberculosis with cavities, which, in childhood, very remarkably, are 
much more often met with in the lower lobes than at the apices of 
the lungs. For a long time I have been in the habit of repeatedly 
and attentively percussing the sternum in all hydrocephalic children, 
on the supposition that the ordinary bronchial glands, swollen into 
large masses, would produce an especial dulness in that region. This 
examination, however, has proved to be entirely fruitless, for the 
bronchial glands, even when they are ever so much enlarged, are 
never enlarged anteriorly toward the sternum, but always laterally 
into the lungs, downward beneath the bifurcation of the trachea, 
and backward toward the spinal column. Hence the reason why no 



DISEASES OF THE NERVOUS SYSTEM. 281 

extensive dulness is ever observed over the sternum, altliough, at 
the autopsy, the tuberculous bronchial glands are found hypertro- 
phied to the size of a pigeon's and even to that of a hen's egg. 

The phenomena presented by the skin are of inferior importance. 
At the commencement of the disease the skin is commonly moist ; 
active sweating of the head is also observed ; but, as the disease ad- 
vances, the skin becomes dry, brittle, and furfuraceous, and no sweating 
takes place again until the fatal accelerations of the pulse come on, 
near the close of life. Sudamina are comparatively rare. The integu- 
ment retains its susceptibility to counter-irritants up to the fatal 
end ; the horrid anointings with ung. tartar, stibiat. or of sublimat., as 
well as the vesicators, act as promptly in hydrocephalic as in healthy 
children. So, too, the simple rubbing in of blue ointment, in children 
with a tender epidermis, produces the ordinary vesicular eruption. 

In the French compendiums there is a description of peculiar 
meningitic spots [taches meningitiqices) ; it is asserted that they 
originate when the integument over the chest and abdomen is 
scraped and much irritated with the finger-nail, and that they leave 
behind them scarlet-red streaks, which, in a few minutes, indistinctly 
merge into the surrounding rose-colored skin. I have often tried to 
produce these " meningitic spots," but have never been able to detect 
any thing more than a red streak, the same kind, in fact, as may be 
produced almost instantaneously by simply scratching any free part 
of the skin in a healthy individual. 

These " meningitic spots " were discovered by Troitsseau, who has 
enriched the Paediatrica with many similar " discoveries." That red 
spots should originate on the skin, in consequence of local congestion, 
sometimes at one place and then again at another, but especially on 
the face, is a phenomenon that by no means belongs particularly to 
hydrocephalus. Their frequent occurrence here finds a very natural 
explanation in the unrhythmical pulse, and in the attending disturb- 
ances of the circulation. 

Headache, likewise, is a prominent and tolerably constant symp- 
tom ; but it does not come on so early as might be supposed, were we 
to judge from the primitive cause of the entire disease, which, in real- 
ity, is to be looked for in the meninges. Indeed, it is almost uniformly 
absent in the premonitory stage, as has already been stated. It comes 
on with, or a short time previous to, the vomiting, and soon becomes 
so severe that older children constantly cry aloud from pain. Younger 
ones pluck at the head and ears with their little hands, and restlessly 
toss the head about or rub it to and fro on the pillow. These mani- 
festations of pain continue as long as the children are in possession of 
their faculties. Usually, no defined place on the skull is complained 
of; still, when asked concerning it, they will point, in the majority of 



282 DISEASES OF CHILDREN. 

cases, to the forehead. In younger children automatic movements 
occur, which also seem to be referable to the headache, and mostly 
consist in carrying one or the other little hand to and from the head 
with great rapidity. Generally, the pains do not intermit, but continue 
unceasingly till coma finally supervenes. 

Older children remarkably often, still not regularly, complain of 
abdominal pams, especially in the epigastric region. These pains 
are materially aggravated on pressure, and may become so intense, 
whenever the stomach or any part of the abdomen is touched, that the 
patients utter loud, painful outcries. They do not, generally, per- 
sist as long as the headache, but they are apt to cease suddenly and 
to return. It is not always possible to attribute them to any patho- 
logical alterations of the intestinal mucous membrane. I have care- 
fully examined the stomach and intestines in numerous autopsies of 
hydrocephalic children, in whom the abdominal pains were extremely 
well pronounced, but have never been able to discover any marked 
morbid changes. 

The shape of the abdomen is extremely pathognomonic of the dis- 
ease. At first nothing in particular can be observed ; but, when vomit- 
ing, constipation, and the general hydrocephalic symptoms, have lasted 
for some time, the abdomen will daily become smaller, plaited, and de- 
pressed, and finally acquire the form of a boat. By very shght press- 
ure, the abdominal aorta can be distinctly felt on the spinal column. 
This boat-shaped belly is generally explained by a paralysis of the 
abdominal muscles, which are said to simply overlie the contracted 
alimentary canal. This condition, however, is by no means produced 
by a paralysis, but by a permanent spasmodic contraction of the 
transversalis and oblique abdominal muscles, in which the muscular 
coat of the intestines also probably participates, for the intestinal tube 
is always found remarkably contracted. A certain degree of hardness 
and tension always remains in the abdominal parietes, even when this 
trough-like formation of the belly is extreme. On the other hand, a 
paralysis sometimes ensues in the last days of life, when the rigid de- 
pression of the abdomen disappears and the retracted abdominal walls 
become again soft and flabby. The case is different with the integu- 
ment covering the abdominal walls. Paralysis affects it very early 
in the disease, as may be seen when a fold, having been raised by 
pinching with the thumb and forefinger, takes a long time to dis- 
appear. 

The retraction of the abdomen is not absent in any case of hydro- 
cephalus, and the description, boat-shaped, is very appropriate, for 
the symphysis pubis, the costal cartilages, and the ensiform cartilage, 
form high promontories, between which the contracted abdominal 



DISEASES OF THE NERVOUS SYSTEM. 283 

muscles represent a deep trough. Goelis regarded this symptom as 
of especial importance, and believed that by it acute hydrocephalus 
could be distinguished from typhus fever with the greatest certainty. 

As regards the external alterations about the skull, they can only 
be observed in cases of unclosed fontanels. These will bulge out 
more and more with the augmentation of the eifusion, and exhibit 
distinct fluctuation. In cases where the fontanels are already closed, 
a peripheral circulation of the veins of the scalp sometimes becomes 
rapidly developed, the result of pressure by the effused fluid upon the 
sinuses of the dura mater. 

The psydiiGcil functions experience disturbances very early in the 
disease, in a manner that has already been described more minutely 
in the stadium prodromorum. The confused, blank look, the morose, 
peevish, irritable disposition, or, in other cases, the utter indifference 
toward beloved persons and objects, are the most striking peculiari- 
ties. Later, when the rest of the symptoms have already placed the 
diagnosis beyond all doubt, actual delirium also supervenes, but gen- 
erally of a quieter kind than in purulent meningitis of the convex 
portions of the cerebral membranes. Furious delirium in the course 
of acute hydrocephalus occurs only exceptionally, and for very short 
periods, and is soon followed by quiet, muttering delirium, and 
this by a permanent state of profound coma. The intensity of the 
dehrium, and the nervous symptoms in general, according to the 
investigations of Hilliet and £arthez, and which I have often been 
able to confirm by dissections, are by no means in exact relation to 
the extent of the disease found in the meninges. In cases of violent 
cerebral symptoms, where a thick layer of exudation and a large 
quantity of miliary tubercles were predicted, traces of them only were 
found here and there at the autopsy ; and, in cases where no delirium 
at all, and only coma, was present in the last period of life, large 
quantities of effusion and extensive miliary tuberculosis have often 
been observed. 

A very common symptom is a loud, mournful cry, recurring at 
longer intervals, and which Coindet considers so pathognomonic of 
this disease, that he unhesitatingly describes it as the " hydrocephalic 
cry." These children also often repeat for whole nights, at regular 
intervals, some monosyllables in a plaintive voice, or repeatedly ex- 
claim, " my ! " which is always accompanied by a loud, deep sigh. 
These symptoms of irritation, extremely distressing and annoying to 
the sympathizing relatives to witness, fortunately do not last, at the 
utmost, longer than six or eight days, and are followed by profound 
stupor. 

When these children have once fallen into a state of coma, thej 



2S4 DISEASES OF CHILDREN. 

never, as a rule, come out of it ; sometimes, however, coma and de- 
lirium alternate, but the former always is predominant. Jiilliet and 
Barthez report the cases as very rare in which perfect consciousness 
returned, only to be quickly succeeded by the previous coma. 

The disturbances of the locomotive apparatus are extremely vari- 
able, and are not completely absent in any case of hj^drocephalus, but 
they generally come on so late in the disease, that they can take but 
little share in the formation of the diagnosis. The stadium in which 
they appear is of great interest to the neuropathologist, and supplies 
some explanation of the innervation of different parts of the body. 
Convulsions and paralysis occur, the former preceding the latter, and 
it is necessary for us to distinguish between the general and local 
convulsions. 

The general convulsions occur paroxysmally. At first the inter- 
vals between the paroxysms are long, three or four days frequently 
passing between the attacks. Generally, however, they recur oftener, 
and in some rare cases may last for many hours continuously. Usually, 
they begin at the inspiratory muscles, producing a suspension of the 
respiration, which is interrupted a few times in the minute by a rapid, 
incomplete act of breathing. They soon extend to the extremities, 
which are vehemently shaken by rapidly-recurring electro-tetanic jerks, 
which alternate with strong supinations of the forearms, and with 
opisthotonos. This very naturally induces marked venous stagna- 
tion ; the face becomes red and even livid ; the eyes injected, roll 
about in different directions, but mostly stare upward to such a degree 
that the pupil and but little of the iris are seen between the half-closed 
Kds. After several minutes, sometimes after two or three hours, these 
general convulsions cease, when the patients, pale as death, sink into 
a state of the utmost prostration, and exhibit a marked aggravation 
of the general condition. 

The local convizlsions attack the most varj-ing groups of muscles 
most frequently those of the face. Here distortions of the upper Up, 
a spasmodic smile, and peculiar sucJdng acts, occur, by which the lips 
are kept in motion for hours. Strabismus is observed late in the dis- 
ease ; sometimes the child squints outward, and then again inward. 
The strabismus is often not permanent, but is subject to the partial 
irritation, or antagonistic paralysis of the various muscles of the eye- 
ball, and in the last days of life it may disappear entirely. 

Tliis symptom, as has been said, comes on late ; still, I can recall 
the case of a child which was brought to me simply on account of 
the daily increase of squinting. In the succeeding days other hydro- 
cephalic symptoms steadily developed themselves, and at the autopsy 
a tubercle as big as a hazel-nut was found in one of the optic thalami. 



DISEASES OF THE NERVOUS SYSTEM. 285 

Another peculiar symptom is the gnashing of the teet\ well known 
to and justly dreaded by experienced nurses. It also is due to a 
spastic contraction of the masticators, and is protracted till complete 
general paralysis takes place. Active partially automatic movements 
of the arms take place, and are described as twitchings, tremors, or 
startings of some of the tendons, while many hydrocephalic patients 
constantly keep their hands about the genitals and perform onanistic 
acts. 

The lower extremities are less frequently attacked by convul- 
sions than the upper ; they are almost always in a semi-flexed 
and paralytic state ; when spasms appear, they will be of the 
character of short tetanic jerks, during which the toes are widely 
separated. 

The muscles of the wa^^e and hacTc are strongly contracted, and 
most of the subjects, when set upright or laid on the side, throw the 
head far backward. The tonic spasm of the abdominal muscles, by 
which the well-known boat-shaped belly is produced, has been already 
mentioned. 

The disturbances of the sensibility, and the derangements that take 
place in the organs of sense, are no less remarkable. In most of the 
patients a decidedly heightened sensibility of the skin is observed at 
the invasion of the disease, which manifests itself by a greater sus- 
ceptibility to external impressions. When raised from the bed ever 
so tenderly, or their posture changed however carefully, or the head, 
abdomen, or hands, touched ever so lightly, they will always resist 
and utter loud cries of pain. But this morbid picture changes rapidly 
as the eflpLision continties to increase, for paralysis of the nerves of 
sensation quickly ensues, and the child may be pricked, pinched, 
or handled, without any special care, may be treated with vesi- 
cants and irritating ointments, yet will make no opposition, merely 
manifesting by a low moan any pain it may suffer. The abolition of 
the sensibility is very strikingly shown in the conjunctiva, which may 
be stroked with the finger without causing the lids to move. 

la addition to the strabismus, which has already been described in 
connection with the motor disturbances, and besides the blank, sur- 
prised look of the eyes, the state of the pupils, and the augmentation 
of the mucous secretion of the lids, are also worthy of notice. The 
pupillary contraction is very transient and by no means constant ; gen- 
erally the pupil has a tendency to dilate very early in the disease, and 
this dilatation perceptibly increases from day to day. Toward the 
end of the disease, the remarkable phenomenon of inequahty of the 
pupils supervenes. Thus, in a child three years old, I noticed in its 
last days of life a unilateral dilatation upon the side on Avhich it 



286 DISEASES OF CHILDREN. 

happened to lie, and at the same time a peculiar oscillatory move- 
ment of the same eyeball, while the pupil and globe of the opposite 
eye remained undisturbed. By laying the child on its other side, I 
succeeded several times, though not always, in producing these altera- 
tions in the eyeball which previously had remained tranquil, wliile 
the other ceased to oscillate. 

The observation of JBrachet^ that, under the influence of a strong 
light, the pupils which are already dilated will contract for a short 
time, and in one or two minutes dilate again, notwithstanding the 
continuance of a stiU more intense light, I have often been able to 
confirm. But, in the last days of life, even the most glaring hght 
fails to make an impression upon the pupils. The secretion of the 
conjunctiva and Meibomian follicles increases during the disease, and 
it becomes necessary several times a day to remove the accumulated 
masses of mucus which collect at the inner angles of the eyes. 

Tlie hearing seems to continue longer, for the children, until they 
are completely comatose, will rouse somewhat upon being called 
by name, and even when spoken to in a low voice. The taste and 
smell become abolished only toward the fatal end ; for the child very 
decidedly objects to being rubbed with ointments of bad odor, and 
refuses to take unpleasant-tasting remedies. 

As regards paralj-sis, it may be remarked that general, lasting pa- 
ralysis, such, for instance, as occurs after a commotio cerebri, is never 
observed. Hemiplegia, on the other hand, occurs in some cases, and 
lasts till death. At the autopsy, in addition to the mihary tubercu- 
losis of the meninges, one or several large, old, yellow tubercles are 
generally found within the brain. ]\Iost frequently paralysis of one or 
the other upper eyelid, or one half of the face, with participation of 
the muscles of the tongue, is observed. Paralysis of one of the 
upper extremities, and more rarely of one of the lower extremities, also 
occurs. The retention of urine in the last days of life is, as has al- 
ready been stated, not to be attributed so much to a paralysis of the 
bladder as to a paralysis of the secretory nerves, for usually the blad- 
der does not become distended so as to be felt above the sjonphysis 
pubis, and the catheter discovers no large quantities of urine. 

Death, as a rule, ensues after violent convulsions of many hours' 
duration, and only exceptionally do the paralytic symptoms steadily 
advance to a fatal termination. 

In the majority of cases it is very easy to make out an approxi- 
mative diagnosis, but whether it is of a tuberculous, or simply of a 
purulent inflammatory nature, it is usually impossible to decide. In 
both processes, the cerebral sjonptoms are alike, only in the simple 
meningitis they come on much more rapidly and are more violent, ter- 



DISEASES OF THE NERVOUS SYSTEM. 287 

aiinate more quickly, and possibly may also end in recovery, while tu- 
berculous meningitis must be put down as an inevitably fatal disease. 
More concerning this may be found in the section which treats of 
simple meningitis. With tjrphus fever it is scarcely possible to con- 
found this disease, if any diagnostic skill at all be exercised. The 
diarrhoea, the tympanitis, the rapid pulse, and the splenic tumor, are 
such constant signs of typhus fever, while the retracted abdomen, the 
constipation, the manner of vomiting, the slow pulse, and the unrhyth- 
mical breathing, are such striking symptoms of hydrocephalus, that 
an error in the diagnosis can hardly happen. It is more probable 
that a chronic gastric catarrh, from which older children become ema- 
ciated, and with which some cerebral symptoms may also be asso- 
ciated, may mislead us, and cause the two diseases to be confounded. 
In the section on intestinal worms a case was related, where a child 
perished under hydrocephalic symptoms, and at the autopsy nothing 
but a large quantity of round-worms was discovered. 

Although these cases must be regarded as extraordinary rarities, 
still we have seen that some verminous patients have wide pupils, that 
they vomit frequently, and even have slow pulse, and consequently 
we may easily be misled to entertain the supposition that we have an 
incipient though irregular hydrocephalus to treat. 

What has been said hitherto has only reference to the completely- 
developed affection, not to the prodromata, which by no means admit 
of any diagnostic precision. This stage is, indeed, frequently con- 
founded with commencing typhus fever, or with simple gastric catarrh, 
with helminthia and irregular and difficult dentition, and to these 
errors no doubt are also due the many reported cases of cured menin- 
geal tuberculosis with hydrocephalic effusion. But the most essen- 
tial points will always be found in the hereditary disjDOsition, by the 
aid of which, in the doubtful cases, we are able to establish the diag- 
nosis with tolerable certainty. If the father or mother, or one of the 
brothers or sisters, have already perished by tuberculosis, the prob- 
ability that the doubtful symptoms belong to acute hydrocephalus 
becomes much greater than when no tuberculosis at all can be de- 
tected in the history of the family. 

Termination and Prognosis. — I recollect to have had, at the very 
commencement of my professional career, a tolerably well-pronounced 
case of hydrocephalus, in which the child, after several weeks, was 
apparently perfectly cured. But the same boy, seven or eight years old, 
one year after his first sickness, again came under treatment, and then 
succumbed to a meningeal tuberculosis and extensive hydrocephalic 
effusion, which was demonstrated by the post-inortem examina- 
tion. 



288 DISEASES OF CHILDREN. 

In all the rest of my h^^droceplialic patients, of which I have had 
at least thirty, death, when the symptoms once indicated cerebral 
dropsy, invariably ensued after two to three weeks. But, by thus de- 
fining the time, we do not intend to say that the disease will always 
run its course Avithin such a period ; for in no disease is it so difficult 
to determine the time of commencement as in the one under considera- 
tion. Formerly it was customary to date the commencement of the 
disease from the day on which the child took to the bed, but attentive 
mothers observe a whole hst of symptoms for weeks and even months 
before this, which they are unable to explain, and for which they con- 
sult the physician. 

As in my own experience not a single child has recovered from 
this disease, and only a single one has overcome one attack to perish 
from a relapse during the follouang year, I am forced to regard the 
prognosis as absolutely fatal. On the other hand, humanity, as well 
as polic}', commands us to afford the relatives a ray of hope till the 
fatal end, for, by inspiring hope, the labor of nursing is vastly light- 
ened, and you retain the patient, and thus keep it out of the hands 
of others who may manage it less humanely. 

Cases are recorded which purport to be recoveries from acute 
hydrocephalus, and their truthfulness is vouched for by names of good 
repute. It is, however, hardly necessary for me to state that I have 
tried the treatment recommended in these cases with the utmost care 
and accuracy, and have, nevertheless, always experienced the same 
uniformly unfortunate result. 

Treatment. — The only essential service which the physician is able 
to render in this terrible disease is to be sought for in establishing a 
strict proph3daxis in these tuberculous families. Every thing that is 
liable to produce cerebral congestion must be strictly prohibited. 
Such children must not be mentally overtaxed, nor allowed to exert 
their faculties for any length of time continuously. They should not 
play at wild, boisterous games, should not run long nor rapidly, nor 
jump, nor dance, etc. Their heads should always be cool, and be well 
protected against the direct rays of the sun. In general, all those 
precautionary measures to be hereafter recommended, in tuberculosis 
as a dyscrasia, are to be scrupulously observed. Especial attention is 
to be bestowed upon the state of the bowels, for constipation is well 
known to be a frequent and an active cause of cerebral congestion. 
The stools, however, should never be promoted by any drastic cathartics 
nor nevitral salts, but those nutriments which experience has proved 
to be constipating should be avoided, and a free use made of those that 
are known to possess slightly-laxative properties. From the earhest 
time to the present, it has been a subject of dispute whether scrofulous 



DISEASES OF THE NERVOUS SYSTEM. 289 

affections, particularly humid eruptions of the head and face, have any 
connection with hydrocephalus, for almost all the children of tuber- 
culous parents suffer from these cutaneous eruptions. Formerly it was 
unanimously conceded that they ought not to be treated except so far 
as cleanliness demanded, for it was observed that, after a certain time, 
occasionally not till after many months, these eruptions ceased to dis- 
charge, formed dry crusts, and when these fell off the normal cutis was 
seen beneath free from any visible cicatrix. There is no doubt that our 
predecessors in therapeutics, who were indisputably more officious 
than the present generation, and knew as well as we do that the cure 
of an impetigo is very much promoted by solutions of nitrate of silver 
and corrosive sublimate, by lead-water, and zinc-ointment, came 
through unpleasant experience to the conclusion that it was safer to 
discard these decidedly efficacious remedies. Of late, such a precau- 
tion has generally been regarded as disadvantageous, and scrofulous 
eruptions of the head are removed as quickly as possible, a practice 
which I too favored for a long time. But it has happened to me 
twice that children, in whom extensive eruptions of the head dried 
up suddenly, were at the same time attacked by hydrocephalus. 
Consequently, since that time, I have entirely renounced this desiccat- 
ing treatment. Of course, I do not intend to declare that there is an 
actual connection between eruptions on the head and acute hydro- 
cephalus, for to establish such a connection those two cases are by no 
means sufficient, and may be contradicted by many hundred others, in 
which the eruption of the head dried up rapidly without being followed 
by any ill effects. But, since it has also been proven by an equal ex- 
perience that they heal spontaneously vnthout any thing at all being 
done for them, it follows that an expectant treatment will probably do 
no harm, and that possibly something beneficial might, in the end, be 
gained by it. 

But what treatment are we to institute when the first symptoms 
of hydrocephalus have actually appeared? The answer may be readily 
divined by recalling what was said as to the prognosis. In few diseases 
is it possible to pronounce all remedies so positively ineffectual as in 
the one under consideration ; and, if in the remainder of this section the 
various methods of treatment hitherto jDroved to be useless are but 
briefly described, it is not with the intention of challenging observa- 
tion, but rather for the purpose of showing the therapeutist how much 
has already fruitlessly been tried in this fatal disease. 

In the first days of the disease, derivatives upon the skin are in 
special favor ; a seton in the nape of the neck, large pea issues in the 
arms, a blister kept in a constant state of suppuration, pustulating 
ointments of tart, emetic or sublimat., cauterizations with potassa 



290 DISEASES OF CHILDREN. 

fusa, all serve the same purpose, to wit, to produce a severe cutaneous 
irritation, with as profuse subsequent suppuration as possible. 

That the antiphlogistic method of treatment has been employed with 
various degrees of vigor, and in every stage, is well known. Leeches 
have been applied to the temples, behind the ears, on the nape, at the 
anus, between the thighs, and large or small venesections in the arm, 
foot, and jugular vein. Ligature of the carotids even has been pro- 
posed, but I am not aware of its ever having been performed. 

The appHcation of cold has also been tried in various ways. The 
ordinary cold-water compresses are constantly kept on the sheared or 
shaved scalp, a bladder filled Avith ice is laid upon the head, the head 
is washed or douched two or three times in the hour Avith cold water, 
and an apparatus even has been invented for the purpose of keeping 
up an uninterrupted irrigation. To the first measures there is nothing 
objectionable, but the irrigation plan is an altogether too elaborate for 
practice. 

" For this purpose," according to Bouchiit, " the neck of the child 
is wrapped around by a water-proof cloth, which communicates with a 
gutter on each side of the bed. A thin stream of water is allowed to 
flow down upon the head of the child from a reservoir suspended over 
it, and is carried off in the gutters above mentioned." Whether 
hydrocephalic children will quietly submit to be thus showered, is 
not stated, but to me it appears extremely improbable. 

Among the remedies capable of bringing about an absorption of 
the deposited exudation, mercury and iodine rank first, and the diu- 
retics next. Of mercurial preparations, blue ointment, corrosive subli- 
mate, and calomel, are most frequently resorted to ; the last two are 
given in large doses, so as at the same time to operate on the bowels. 
Even tartar emetic, as high as several grains daily, has been adminis- 
tered as a general alterative remedy. Phosphorus also has been tried, 
on account of forming one of the component parts of the brain. Of the 
diuretics, nitre, digitalis, squills, and juniper — of the antispasmodics, 
assafoetida, camphor, moschus, castoreum, have been used. In restless, 
delirious children, opium has been given with marked tranquillizing 
effect, but the majority of physicians dread the paralyzing action of 
this remedy, and too readily believe that the steadily-increasing 
deterioration of the patients is in part caused by the opium. But he, 
who has seen a number of such cases perish without narcotics, will 
administer opium, or, still better, morphine, without timidity and with- 
out suffering any compunction of conscience, in cases of great restless- 
ness and severe headache. 



DISEASES OF THE NERVOUS SYSTEM. 291 

The short but extremely sad resume of the whole treatment then 
is, that at first the treatment, as for a simple, non-tuberculous men- 
ingitis, is mildly antiphlogistic, with small doses of calomel, blue 
ointment, and cold ablutions of the head, and perhaps also by the 
application of moderately-active cutaneous irritants, and nervous 
excitement is tranquillized by morphine. Torturing, violent appli- 
cations are to be avoided entirely, for their inefficiency has often 
enough been made evident, and it is admitted that methods of treat- 
ment which torture are only permissible when there is any hope of 
benefit. And yet, in a disease that is universally regarded as fatal, 
all possible therapeutic experiments are practised. 

(2.) Meningitis Simplex, Pueulenta, and Encephalitis— 
(Simple or Purulent Inflammation of the Meninges and the Brain). — 
Although chronic hydrocephalus very naturally ranges itself with 
the acute, still a few words may be said here of simple meningitis, on 
account of the many analogies between it and the preceding disease. 

It is a much rarer affection than acute hydrocephalus, and occurs 
no oftener in children than in adults. In this disease, portions of the 
brain proper in proximity with the meninges almost alwaj^s are in- 
volved, and, as inflammation of the meninges cannot be clinically 
distinguished from congestion and inflammation of the cerebral sub- 
stance proper, it is, therefore, best to describe these different morbid 
processes in one clinical discourse. 

Etiology. — Occasionally the causes of this disease can be ascer- 
tained with great accuracy. The usual causes are traumatic — cere- 
bral concussion, which, on account of the livehness and awkwardness 
of the child, often enough occurs, injuries acting directly upon the 
cerebral substance, great heat and cold, insolation, immoderate mental 
exertions, and the propagation of inflammation from adjacent organs. 
The most frequent cause in this respect is otorrhoea ; less frequently 
the meningitis takes its source from an ozoena, or from an inflammation 
within the orbital cavities. Meningitis also occurs after erysipelas, 
but, in the majority of instances belonging to this class, the erysipelas 
seems to be of a traumatic nature, and hence a purulent absorption 
through the osseous vessels must be assumed. Those cases of menin- 
gitis following metastases, repercussed cutaneous eruptions, sup- 
pressed epistaxis, etc, are mostly problematical, though even for these 
some very reliable vouchers are found in medical literature. At cer- 
tain times this disease has been seen to appear in an epidemic form. 

Pathological Anatomy. — The dura mater participates in the in- 
flammation in traumatic cases only, and in these the morbid process 
always remains circumscribed, and produces a flat, fibrinous, or purulent 
layer of exudation upon that membrane. In chronic cases, which in 



292 DISEASES OF CHILDREN. 

children are very infrequently observed, the dura mater becomes 
markedly thickened, and thrombi form in one or the other of its 
sinuses. In simple meningitis the inflammatory exudation is located 
between the arachnoid and pia mater, and penetrates deep into the 
convolutions and dejDressions of the brain. As an important distinc- 
tion from tuberculous meningitis, it is never found so diffused over 
the base of the brain as upon the upper surfaces of the hemispheres. 
It, however, extends down over the sj^inal cord, and thus adding men- 
ingitis si^inalis. The exudation is yellow, yellowish green, fibrinous, 
or purulent, and is scarcely ever more than a line in thickness. It is 
either bathed in a large quantity of turbid, opaque serum, in which it 
often liquefies, and then becomes converted into a flocculent, greenish, 
glittering fluid, or it is poor in serum and rich in fibrin, so that, when 
the arachnoid is pulled ofi", this false membrane partly remains hang- 
ing on to the arachnoid membrane and partly to the brain. The pecu- 
harity is also worth mentioning, that acute hydi'ocephalus never occm-s 
in combination with simple meningitis, but invariably supervenes upon 
tuberculous basilar meningitis. This is due undoubtedly to the fact 
that in the former the direct continuation of the pia mater into the 
cerebral ca\'ities is free ; in the latter, on the contrary, only the base 
of the brain becomes the site of the gelatinous mass of exudation. 
The outer stratum of the brain-substance may be involved and soft- 
ened, or it may be in a perfectly normal condition. 

This simple meningitis, which occmrs in an extremely acute form, 
though generally terminating fatally, cannot, we may judge from 
the distinct traces of resolution occasionally found, be regarded as 
a hopeless disease. In the favorable cases the exudation becomes 
transformed into a fibrous structvire, the pia mater into a milk-white, 
firm membrane, and becomes united with the cerebral cortex on the 
one side, and with the arachnoid on the other. 

Symptoms. — Simple meningitis, when it is not of a' traumatic 
origin, or is the result of an otorrhoea, attacks almost exclusively 
well-nourished, robust children, which bear no trace of scrofula. In 
cretins, who are not infrequently victims of this disease, the autopsy 
exhibits, conjointly with the old h}-pertrophies of the meningitis, a 
freshly-deposited exudation, so that the fatal disease in such case 
must be regarded as a relapse of the former meningitis. The com- 
mencement of the disease is extremely acute, and, bj' the second or 
third day, the process has already attained to its climax. All the pro- 
dromata that have been described in connection with hydrocephalus 
acutus are totally absent here. But a hydrocephalus that has already 
reached its acme can no longer be diagnosticated from a meningitis 



DISEASES OF THE NERVOUS SYSTEM. 293 

of the hemispheres, and only the course of the two diseases furnishes 
the requisite data for a diiferential diagnosis. 

In simple meningitis, as well as in the tubercular form, vomiting 
without retching, constipation, slow pulse, unrhythmical respiration, 
violent headache, retracted abdomen, and the whole train of nervous 
disturbances which have been more minutely detailed in the preced- 
ing section, occur. The following distinctions, however, may be made 
available : The course of meningitis simplex is more rapid, for death 
usually ensues between the third and sixth day after the invasion of 
the disease, and the temperature of the skin, particularly on the head, 
is correspondingly more elevated. The delirium is extraordinarily 
severe, even furious ; the face has a wild, confused expression, and the 
convulsions and contortions of the body are of extreme severity. The 
piilse is less retarded than unrhythmical, the vomiting is not so con- 
stant, and may even be entirely absent. 

When such children do not succumb to the meningitis in the first 
few days, the symptoms will abate very gradually, and recovery may be 
hoped for ; but, as the diagnosis between the disease under consideration 
and acute hydrocephalus is difficult, recovery must continue extremely 
doubtful. A marked emaciation supervenes, and a mental weakness 
is liable to follow, a result which I have twice witnessed in my own 
practice. The great similarity in the termination of meningitis and of 
hydrocephalus makes the assertion, that acute hydrocephalus is some- 
times curable, quite excusable, for it is indeed possible, although very 
improbable, that children of tuberculous parents may exceptionally 
acquire a simple meningitis, from which perchance they may recover. 

Treatment. — In this disease, a mercurial treatment is decidedly 
eff"ectual, the two children which I saw recover having been treated 
exclusively with mercury internally and externally. For this purpose, 
a drachm of blue ointment is rubbed in daily upon the sheared head, 
and gr. ss. of calomel is given every hour. In both children the dis- 
ease had reached a most critical degree, as evinced by cerebral vomit- 
ing, unrhythmical pulse, retracted abdomen, and convulsions. Severe 
stomacace supervened, however, on the third day, and, immediately 
upon that, a gradual abatement of all the symptoms followed. Cold 
affusions of the head, repeated every two or three hours, exercise a 
very favoralile influence upon the delirium. These are best performed 
by -wrapping the breast and arms of the child in a shawl or cloth, the 
head is then held over a basin, and cold water is poured upon it from 
a moderate height for one or two minutes. A mitigation of the cere- 
bral symptoms, although only temporary in its duration, always fol- 
lows this proceeding. 
20 



294 DISEASES OF CHILDREN, 

Five cbildren I treated with leeclies, but all succumbed to the disease. 
As sudden blancliing of the lips and rapid pulse followed the loss of 
blood so directly, they were regarded as the effects of this procedure. 
On the other hand, in those two children which recovered, no leeches 
were employed, and therefore, according to my own experience, I 
have to regard the treatment without leeches as the correct one. The 
stomacace and salivation, occurring as the effects of mercury, cannot 
be regarded as critical, though they inay appear in cases which termi- 
nate fatally on the second day. Generally, it is easily recovered from 
by the administration of chlorate of potassa, of which a drachm, dis- 
solved in several ounces of water, may be consumed every day. 

Some maintain that, in cases of great excitability, opium should 
be used in combination with mercurials, but I am unable to approve 
of this ; on the contrary, my experience leads me to consider narcotics 
as contraindicated in this terrible disease, which rapidly destroys by 
paralysis. I am the more opposed to the use of narcotics, that we 
possess in cold such a valuable remedy against the excitability. 

Compression of the carotids with the thumb and index-finger 
against the sj^inal column, or the lateral walls of the larynx, for a 
namute or two, repeated several times a day until the head symptoms 
abate, has been highly recommended in France. 

That this compression, when feebly executed, is only an illusory 
remedy, and when forcibly performed is apt to compress the jugular 
vein rather than the carotid artery, and thus in the end do more harm 
than good, has been conclusively proved by /S. Leicis. This measure, 
therefore, has notliing but an historical interest. 

The marked emaciation, which is the result of a meningitis, 
must be treated by a nourishing diet, by stimulants, iron, quinine, etc. 
For the mental weakness, which this disease in most cases leaves be- 
hind, there is no other remedy, to my knowledge, than mental rest, 
along with a tranquilUzing, psychical treatment. 

(3.) Insolatio — SuJsrsTEOKE. — Insolation may next engage our 
attention, very properly ranking next to purulent meningitis, although 
the pathological anatomy exhibits no direct connection between the 
two diseases. In the former no purulent effusion is found upon the 
meninges, only intense injection, a slight augmentation of the reddish 
contents of the ventricles, and softening of the cerebral substance. 

Symptoms. — Children who, with uncovered heads, have exposed 
themselves for some time to the direct rays of the sun, return to the 
house with flushed face, reddened neck and arms, and soon complain 
of an intense headache. The red color of the parts of the sldn men- 
tioned does not disappear, as after simple overheating, but remains for 
many days in the shape of small, elevated erythematous spots. After 



DISEASES OF THE NERVOUS SYSTEM. 295 

several hours delirium comes on, often of a violent nature, with the 
development of an excessive muscular power, flushed face, injected 
eyes, contracted pupils, strong pulsation of the carotids, hot skin, dry 
tongue, and intense thirst. With this array of symptoms, a severe 
meningitis may well be suspected, but the pulse is very much accel- 
erated, and, in the majority of cases, rhythmical, while in the puru- 
lent meningitis it often becomes retarded, and sometimes is un- 
rhythmical. Vomiting also is absent, unless undigested food exist 
in the stomach. 

The course of insolation is quite different from meningitis. After 
a half a day to at most two days, all these symptoms disappear. The 
child, at first, falls into a restless, then into a profound sleep, and 
wakes from it with complete consciousness, and, at the end of two or 
three days more, the health is fully reestablished. But instances have 
occurred where death took place at the very commencement of the 
attack. These cases, however, form the exception, and are rarely met 
with in our moderate climate. 

Treatment. — Venesection, it is true, produces some abatement of 
the symptoms, but, in consequence of the furious delirium, it is im- 
possible to perform the operation, and the use of leeches is opposed 
by the same condition. The best and quickest means is always to 
cut the hair as short as possible with a few sweeps of the scissors, 
and then apply the cold douche to the head every hour. This pro- 
cedure invariably produces a decided moderation of the furious symp- 
toms. Ice may be applied to the head, sinapisms to the extremities, 
calomel and jalap may be given internally, and stimulating clysters 
administered. Almost all children recover from this seemingly ex- 
tremely dangerous condition.* 

(4.) Hydrocephaloid aistd Ireitatio Cerebri. — Marshall Hall 
found some resemblance between acute dropsy of the head and the 
symptoms originating in atrophic children due to anaemia, and on that 
account called the latter condition hydrocephaloid disease. This dis- 
ease, although in no way based upon pathological anatomy, has been 
admitted into all the text-books, and I shall therefore also give it a 
bi-ief discussion here. Although it is not a distinct disease, but rather 
a termination of such, still, the name deserves to be retained, if it were 
only for the sake of convenience, in order to describe a whole group 
of symptoms by one word. By irritatio cerebri, therefore, is under- 
stood almost exclusively those cerebral symptoms which commonly 
supervene in consequence of interrupted nutrition, or of atrophy, so 
that the symptoms of hydrocephaloid and of irritatio cerebri may, with 
the utmost propriet}'', be considered together. 

Symptoms. — After various exhausting diseases, generally such as 
* See treatment of typhus fever, page 493. 



296 DISEASES OF CHILDREN. 

diarrhoea, abstraction of blood, etc., cliildren under one year of age are 
seized with a class of cerebral symptoms which, at first sight, without 
due reflection, might certainly give rise to the thought of a material 
alteration, an exudation in the brain. The most striking of these 
symptoms is an incessant rubbing to and fro of the head, or a boring 
of it into the f)illow, by which the occiput is wholly deprived of hair, 
and small abrasions of the scalp, loss of epidermis, and furunculosis 
often result. Many cliildren also pluck the head with their hands, 
pull the hair and ears, and scratch their faces until they bleed, and 
cease to notice the objects by which they are surrounded. The eye- 
lids are half closed, and, in the majority of cases, the globe is rolled 
upward. The upper extremities are in a constant state of rigid flexion. 
The thumbs are drawn into the palms, and the fists closed so firmly 
that considerable strength is requisite to open them, and the palms 
of the hands become denuded of epidermis. Tliis latter sign is espe-r 
cially observed in children who frequently handle the fermenting 
sugar-teat. The lower extremities are likewise rigid, either extend- 
ed or contracted, and the muscles of the nape of the neck are so firmly 
contracted that, if the child be laid upon his side, the body will curve 
far backward. Occasionally, particularly toward the latter end, te- 
tanic spasms supervene. Almost all these children vomit immediately 
after food or drink has been administered — a fact which gives this 
disease a resemblance to an exudative cerebral afi"ection. It is also 
true that this vomiting occurs without retching or exertion (as is gen- 
erally the case in young children), but it has its foundation in an irri- 
table state of the gastric or intestinal mucous membranes. On ex- 
amining the heads of children, who, in consequence of profuse 
diarrhoea, have become atrophic, and in whom these cerebral symp- 
toms have appeared, the temperature will be found to be elevated, 
the anterior fontanel depressed, the cranial bones overlapping each 
other ; in short, all the signs of such an extremely aggravated state of 
cerebral atrophy that we are enabled with the utmost certainty to 
prognosticate a fatal termination. Constipation is of more frequent 
occurrence than diarrhoea ; but, should the latter exist, it is never 
copious ; the appetite, in most cases, is slight, though sometimes a 
wonderful greediness comes on, and continues almost till death. The 
pulse, imlike that in genuine hydrocephalus, is extremely rapid, and 
the resjDiration, although unrhythmical, still almost always perceptibly 
accelerated. At first, the child will cry incessantly for several days 
and nights ; toward the end it is only able to utter a low groan, or 
single abrupt cries. 

Autopsy. — The brain is found softened and watery, the gray sub- 
stance pale and not sharply defined, but passes gradually into the 



DISEASES OF THE NERVOUS SYSTEM. 297 

wliite portion. The meninges are infiltrated with serum, and in the 
ventricles only the normal amount of fluid is found. It is probable 
that the quantity of fat in the brain has become decidedly diminished, 
and in this manner the cerebral symptoms may be explained. I am 
not aware that any chemical investigations have been instituted in 
this direction. 

Treatment. — Every thing that has already been recommended in 
the treatment of intestinal catarrh and enteritis folliculosa is appli- 
cable here ; and the reader is therefore referred to that section. To 
coimteract the continuous crying and sleeplessness, cold ablutions of 
the head, applied by the naked hand, the keeping of the body dry 
and warm, are, as yet, the only means worthy of recommendation. 
After the ablutions, rest for one or more hours usually ensues. The 
only active remedy capable of restoring such an extremely prostrated 
nutrition is, the breast of a healthy wet-nurse, the only precaution 
necessary to take being, not to wean the wet-nurse's child until the 
sick chUd is able to suck, which will often take several days. The 
necessary consequence of neglecting this precaution would be to sub- 
ject the wet-nurse to sickness, a mastitis, or a suppression of the milk. 

(5.) Htdeocephalijs Chronicus (Chronic Dropsy of the Head). 
— Theoretically, an external and an internal^ a congenital and an ac- 
quired chronic dropsy of the head are distinguished. Practically, how- 
ever, these forms cannot be separated from each other, for it is impos- 
sible to assert, especially as regards the latter distinction, whether the 
child came into the world with a small effusion which subsequently 
increased markedly, or whether it was first formed perfectly normally, 
and only latterly became hydrocephalic. The external dropsy of the 
nead is almost always congenital, and usually complicated with hernia 
of the brain, and on that account will be returned to further on. 

Pathological Anatomy. — The most extensive effusion into the 
ventricles takes place in the foetus, and the delivery often becomes 
impossible till perforation has been resorted to. In congenital dropsy 
of the head, the quantity of the water may increase to several pounds, 
according to some authors even to ten pounds. The ventricles are 
distended into large sacs, and their upper walls so attenuated that 
they rarely measure a line in thickness, or they may be reduced 
to so thin a covering that it is impossible to dissect it off. The con- 
volutions of the cerebrum are faintly marked on the upper surface of 
the brain, may be perfectly smooth, and the meninges extremely at- 
tenuated. The deformity of the cranium corresponds with the quan- 
tity of water witliin it. The ossification of the cranial bones, naturally, 
is very much retarded, the sutures become wide enough to admit a 
finger, and the anterior fontanel attains a diameter of several inches. 



298 DISEASES OF CHILDREN. 

Should life last for several years, an ossification finally takes place ; it 
is effected by the bones sending out from their borders long radiating 
projections toward each other till they become united, and thus form 
excavated shallow sutures between them ; or, finally, they may be 
united by a number of ossa triquetra becoming develoj^ed in the fon- 
tanels and between the separated bones. As these forms of union 
never proceed uniformly, one suture becoming closed on one side 
earlier than upon the other, marked malformations of the skull result, 
to which Virchow in particular has directed his attention. The most 
common abnormalities deserving to be mentioned are, the immoder- 
ately long, broad, high, round skull ; the blunt, quadrangular cranium ; 
and the cranium that slopes in the direction of the transverse or lon- 
gitudinal diameter. The effused fluid acts no less strikingly upward 
than it does downward. The corpus striatum and optic thajami are 
flattened and forced asunder by the dilatation of the third vejitricle, 
while the floor of the latter is very much attenuated and has become 
transparent. The corpora quadrigemina, through the same cause, are 
flattened, the commissures mangled and attenuated, the crura cerebri 
forced asunder, and the septum ventriculi broken through in many 
places. The cerebellum is diminished, out of proportion to the cere- 
brum, and flattened ; also the pons VaroUi and the pineal gland. 

In acquired hydrocephalus, or that variety which develops itself 
in children who, from several months up to many years of age, enjoy 
a perfectl}' normal physiological development of the skull, the morbid 
alterations are less striking. The quantity of the serum in these 
cases depends upon the formation of the cranial bones ; whether any 
and which sutm'es are ossified ; and whether, at the commencement of 
the accumulation of fluid, a divergence of the bones can take place. 
The quantity of serum in these cases does not generally amount to more 
than from three to six ounces, and the alterations of the shape of the 
skull and brain, of course, never become so marked as in the congen- 
ital dropsy, which, after birth, continues to grow rapidly. The de- 
scription of the external forms of the skull will find a more appropriate 
place in the section on Symptomatology. 

Among the causes of chronic hydrocephalus, neoplasms in par- 
ticular deserve to be mentioned, by which a sinus is made impermea- 
ble, and thus the accumulation of the serum is produced. Certain 
other complications, which coujd be brought into direct connection 
with hydrocephalus, tuberculosis particularly, so common in the acute 
form, do not here exist. 

The chemical analysis of the effused fluid has taught us that 
the dropsical serum possesses very similar properties to that of acute 
dropsy of the head. Its reaction is alkaline, a trace of albumen is 



DISEASES OF THE NERVOUS SYSTEM. 299 

found, and the proportion of potassium to sodium is different from 
that found in the blood-serum. This subject is treated in detail at 
page 273. 

Symptoms. — On examining the skull, marked deviations from the 
normal form are found. The earlier the hydrocephalus begins, the larger 
will the cranium become ; it is largest where the process begins in 
utero, and smallest in the cases occurring after closure of the sutures. 
The earlier the exudation, or, more correctly speaking, the augmenta- 
tion of the physiological exudation of the fluid contents of the cere- 
bral cavities, occurs, the more pronounced will be the globular form 
of the skull ; the later this happens, the less will be the deformity. 
If some of the sutures have become ossified, while others are still in a 
distensible condition, the skull will always be elongated in the direc- 
tion of the closed suture. For the purpose of making the case com- 
plete, it is well to institute measurements of the enlarged skull, by 
which the largest circumference (that which passes over the frontal 
prominences), the distance from one ear to another, and from the pro- 
tuberantia occipitalis externa to the root of the nose, may be ascer- 
tained. Practically these measurements have but little value, for the 
arching of the forehead and the attitude of the temporal bones fur- 
nish sufficiently accurate data by which to judge of the degree of the 
abnormal enlargement. They may, however, serve to instruct us as to 
the rapidity with which the disease progresses, for thereby it is strik- 
ingly seen that the distention of the cranium does not take place uni- 
formly and gradually, but by fits and starts, the disease often being at 
a stand-still for long intervals. If the anterior fontanel is still ununited, 
as is the case in most instances, it will become distended to a great 
vault of several inches in diameter, will fluctuate distinctly, and feel 
tense. This arching and tension always continue until death, even 
when the body in general is very much emaciated. The synchronous 
rising of the fontanel with the pulsation of the radial artery can be 
very strikingly noticed, while its elevation and depression with the 
respiration are totally abolished. Great attention has been for some 
time bestowed upon the auscultation of the anterior fontanel, and it 
has certainly been clearly shown that a slight breathing or blowing 
murmur is perceived over various places on the skull, particularly over 
the large fontanel of rachitic children, but never heard in hydrocepha- 
lus. It is very easy to understand why these blowing murmurs dis- 
appear in cases of hydrocephalus, as they most probably originate in 
the unequal sinuses of the dura mater, and these must become seri- 
ously compressed by the increasing quantity of the water within the 
skull. The best index is the position of the temporal bones. Wliile, 
in the healthy child, they stand perpendicularly, in the hydrocephalic 



300 DISEASES OF CHILDREN. 

child they diverge greatly at the upper part, so that, in extreme cases 
of serous distention, the auricle is hid from view when looking down 
upon the heed. After the disease has existed for some time, the up- 
per wall of the orbit, through the continuous pressure of the brain, be- 
comes flattened, and, as a result of this, the eyeballs protrude more 
and more, until the whole cornea, and even the upper segment of the 
sclerotic is exposed, a condition that gives a peculiar glaring and un- 
natural look to the features. From the same cause, augmented press- 
ure within the skull, a strong collateral circulation occasionally also 
forms in the scalp and frontal integument, the distended vessels ap- 
pearing as tortuous blue cords. This discoloration produces a singular 
appearance. The face, as contrasted with the dimensions of the ver- 
tex, appears extremely diminished, but, aside from that, retains its 
normal proportions. In most cases in young children, with congenital 
hydrocephalus, it is very lean, sharp, and has a senile appearance ; 
while in older children it may remain j^lump and round until death. 

The functional disturbances are numerous, and vary in almost 
every case. In the acquired form these symptoms come on either 
very gradually, or are ushered in by a fever and a few phenomena, 
such as occur in acute hydrocephalus — outcries, vomiting, headache, 
gnashing of the teeth, and delirium. The mental capabilities some- 
times remain unaffected for a remarkably long time, and it is sad 
to behold the little sufferer, who, with a monstrous head, suffering 
involuntary fecal and urinary evacuations, with limbs paralyzed or 
contracted, yet answers all questions rationally, and even reasons 
acutely. In some cases, however, mental aberration is among the 
early symptoms, ending in imbecility. Of the senses, that of %asion 
most frequently disappears first. The pupil becomes moderately 
dilated and fixed, and the sensibility to light so totally lost that 
children will gaze for a long time, and sometimes prefer to look 
directly at the sun. Strabismus is of less frequent occurrence in 
this form than in the acute hydrocephalus. A nystagmus of one 
or both eyeballs is oftener observed, and the pupils at times are 
unequally contracted or dilated. The other senses, in most cases, 
remain up to a brief period before death ; this is especially true 
of the sense of hearing. The sensibility of the skin is diminished 
or abolished, especially in the paralyzed extremities. Hemiplegia 
occurs less frequently than bilateral paralysis, the loAver extremi- 
ties being the most frequently affected. Tliis is followed by an 
insensibility, then a paralysis of the sphincters of the bladder and 
rectum, thus making the care of these children extremely laborious. 
Bed-sores are unavoidable ; yet, as they fortunately accelerate Aerv 



DISEASES OF THE NERVOUS SYSTEM. 301 

much the termination of the little patient's sufferings, are blessings in 
disgmse. Contraction of the muscles is of frequent occurrence ; con- 
vulsions are occasionally observed, and death may occur during a fit. 
The remainder of the phenomena, which characterize an attack of acute 
hydrocephalus, as a rule, are absent in the form of disease under con- 
sideration. The respiration, which, in the former, is distinguished by 
the absence of the rhythm, in the latter is normal ; likewise the re- 
tardation of the pulse is not ordinarily met with here. The digestion 
may remain perfectly normal, no vomiting and no constipation ensu- 
ing; or, if they do occur, they are only temporary. This explains 
the continuance of a good state of nutrition sometimes for years. If 
no other disease, such as tuberculosis or intestinal catarrh supervene, 
the nutrition will not be impaired ; the appetite often becomes of a 
voracious character. The adipose tissue of the body becomes abnor- 
mally augmented. The patient complains only temporarily of head- 
ache, and febrile attacks are often due more to accidental interciurent 
affections than to hydrocephalus per se. Acute accessions may cause, 
for a few days, the very picture of an acute hydrocephalus, still the 
deterioration does not progress as incessantly as in this latter condi- 
tion, for a stasis occurs in the critical symptoms, and the disease 
again assumes its chronic character. 

The course, as may already have been inferred from the preceding 
history, is of a chronic nature. Large congenital dropsies of the 
head are quickest terminated ; they, indeed, are exposed to the great- 
est danger during the delivery, and only very exceptionally endure 
the injurious effects of pressure during that act. Very moderate 
effusions, which have been acquired much later, are tolerably well 
borne for many years, and such persons may attain to a middle age ; 
indeed, a case of hydrocephalus is recorded which died at the age of 
fifty-four years. 

Death may occur as an immediate effect of the cerebral lesions, 
from convulsions or increasing coma and collapse, where, at the au- 
topsy, fresh meningitis or meningeal hiemorrhage may be found con- 
jointly with the effusion. Bed-sores and their sequelae, pyemia and ex- 
haustion, may furnish the next cause. Tlie subjects, in the majority 
of cases, however, die from intercurrent affections, chiefly from intes- 
tinal catarrh and enteritis folHculosa, or during dentition, from pneu- 
monia, meningitis, or an acute exanthema. These affections in chronic 
hydrocephalus oftener terminate fatally than in previously healthy 
children. 

* 

The deferential diagnosis in the well-pronounced cases has no 
difficulties, a diagnostic error being Avholly improbable. Small col- 
lections of water, on the contrary, by no means furnish very striking 



302 DISEASES OF CHILDREX. 

symptoms, and may be very easily confounded with racliitis of the 
skull, or with simple hyj^ertrophy of the brain and of the cranial bones. 
The main distinction between chronic hydrocephalus and rachitis of 
the skull consists in this, that the temporal bones in the former are 
always directed outward, while in the latter disease they stand per- 
pendicularly, even when the anterior fontanel has become very large. 
All the hydrocephalic functional symptoms are absent here, and the 
attenuation of the skull itself generally is not found diffused over the 
whole surface, but confined to the posterior parts, while the frontal 
bones display the usual rachitic hypertrophy, and the remaining por- 
tions of the skeleton, thorax, and extremities, are similarly affected. 
Cerebral hypertrophy is likewise unaccompanied by any of the hydro- 
cephalic symptoms. It almost always originates in consequence of 
rachitis of the skull, and the bones are markedly hypertrophied. But, 
after all, we are entirely unjustified in speaking of hypertrophy of the 
brain from mere eye measurements, so long as no accurate weighings 
of the brain, in comparison to the entire weight of the body, have 
been instituted, and the medium number fixed upon. 

Therapeutics. — I know, indeed, certain children with chronic hy- 
drocephalus, in whom no augmentation of the serous effusion has 
taken place for years, and who are in a tolerably good state of men- 
tal and corporeal development, but that an actual cure ever was accom- 
phshed, so as to secure the social usefulness of the patient, we have no 
proof. To keep these children alive as long as possible, they must be 
carefully nursed, and their diet accurately regulated. Though the ac- 
tion of diuretics in promoting the absorbing of the hydrocephalic fluid, 
and its subsequent elimination, seems to be extremely problematical, it 
appears proper to give them. For this purpose such only should be 
chosen as exercise no general weakening influence, for example, 
juniper, digitalis, acetate of potash; iodide of potassium, mercury, 
tartar emetic, and drastics generally, are to be avoided. A tonic and 
stimulating treatment cannot be injurious, particularly when proper 
attention is at the same time paid to the condition of the bowels. 
Locally, the most various ointments and fomentations have been em- 
ployed, and, so long as the children are not tormented with them, 
they are not objectionable. The continuous strapping of the head for 
years with adhesive plaster, so warmly recommended by Enrjlemann^ 
as well as the puncturing and evacuating of the contents of the ven- 
tricles in those cases where the fontanels are still unclosed, has been 
tried by a few surgeons eager to operate, and has been abandoned 
because of its total inefficacy. 

(6.) Encephalocele (Congenital Hernia of the Brain). — Her- 
nia cerebri is always congenital, and produced by an immoderate dis- 



DISEASES OF THE NERVOUS SYSTEM. 393 

tention of the brain, as an effect of which the proper development of 
the cranial bones cannot take place. In these cases a tumor is fomid 
immediately after birth on some part of the skull, most frequently in 
the occipital region, and, on examining the parts more closely, the 
bones will be found to be annularly defective. The size of this 
tumor varies between that of a child's head and a small nut, and 
chiefly consists of the water which in all cases surrounds the pro- 
lapsed portion of the brain. The narrower the bony chasm, the more 
pediculated will be the tumor ; and the wider it is, the more flattened 
the prolapsed part will be. Its covering consists of an atrophic, hair- 
less cutis, which is united with the pericranium and the meninges. 
In large hernia, the integument may be so atrophied that the sac 
bursts from pressure at the delivery, whereupon death is the imme- 
diate result. Hernia cerebri occurs most frequently at the occiput, 
upon or beneath the posterior fontanel. It also occurs at the root of 
the nose, or angle of the eye, at the anterior fontanel, and very rarely 
through the temporal bones. When it makes its exit at the root of 
the nose, the nasal bones will be found forced asunder, and the dis- 
tance between the eyes increased. 

By compression the tumor may be entirely reposited, or consider- 
ably diminished, but the procedure always induces pain, and, when 
the pressure is kept up, rnay give rise to cerebral phenomena, such as 
convulsions, tetanic spasms, stupor, and syncope. In small tumors, 
with tough coverings, an early death is by no means an absolutely 
necessary occurrence. But the growth of the tumor, which always 
keeps pace with the other portions of the body, exposes it to almost 
unavoidable contusions and other injuries, which give rise to a chronic 
meningitis, and thus it happens that it is one of the rarest occurrences 
to meet with an adult or a child with hernia cerebri of several years' 
standing. Although life, with very great care and attention, may be 
preserved for a few years, still, the mental developments remain very 
much retarded, and imbecility is invariably the result. 

Treatment. — In very small, entirely reducible hemiae, a radical 
cure is said to have been effected by the continuous maintenance of 
the sac within the aperture till it is closed by bony deposit. When 
the reposition is not complete, as is generally the case, and when 
severe cerebral symptoms are induced by the reduction, we must be 
content with simply protecting the dangerous spot from external 
injuries by a hollow piece of lead, or a properly-constructed leather 
covering. By this means the sufferer may live to an advanced age. 
Among the anatomical collections in this place, is a skull of an adult, 
on the occiput of which is an opening the size of a penny. The edges 
of this opening are round and smooth, and its history states that dur- 



304 DISEASES OF CHILDREN. 

ing life a cerebral hernia protruded through it. The removal, or the 
deligation of such a hernial tumor, according to Souchut^ always 
gives rise to a fatal meningitis. Consequently, the operation should 
be totally discarded. Better results may be expected from punctur- 
ing the tumor Avith a trocar, or, still better, with a simple needle in- 
troduced a number of times, and thus evacuating the contents. By this 
means we may often succeed in so diminishing the size of the tumor 
that a protective instrument may be applied, which otherwise would 
have been almost impossible. Though the secretion accumulates again 
after the puncture, the hernia, after the operation has been repeated 
six or eight times, remains permanently reduced in size, and a marked 
improvement in the whole condition is brought about. 

(7.) Sclerosis or the Bkaix. — Induration of the brain in chil- 
dren is extremely rare. Rilliet and Sarthez, and Weber, have reported 
single instances only. The sclerosis of children, like that of adults, 
either involves the whole brain, or only small portions ; the degree of 
induration fluctuates between an almost imperceptible hardness and 
a cartilaginous consistence. In the latter case, it is always combined 
with atrophy, loss of substance, and textural alteration. A slight 
degree of general induration occurs more frequently than any of the 
other forms, such as is sometimes found at the autopsy of fatal cases 
of scarlatina and tj-phus fever. The rarity of the partial induration is 
readily explained b}' the circumstance that cerebral apoplexy in child- 
hood is extremely rare, and that its resolution is the principal cause 
of this indiu*ation. In somewhat extensive meningeal hasmorrhage, or 
pixrulent meningitis, the adjacent parts of the brain usually partici- 
pate, and the sclerosis then forms the finale of these processes. These 
cases are characterized by an almost cartilaginous hardness, the indu- 
rated portions presenting a dirty, grayish-yellow color, which, to a 
great extent, takes the place of the gray substance, though the white 
substance also becomes more or less affected. Carcinoma of the brain, 
whose nature will be discussed in one of the following sections, should 
not be confounded with this induration. This cerebral sclerosis pos- 
sesses little else than anatomo-pathological interest, for the sjTnptoms 
produced by it are not characteristic, and, consequently, no one is 
capable of diagnosing it. The sj'-mptoms it may occasion are epilepsy, 
idiocy, and neuralgia of various kinds. 

Treatment. — This must naturally be directed to the symptoms. 
The cure of the induration has never, to my knowledge, been accom- 
plished. Narcotics, nervines, and tonics, will be the agents, ac- 
cording to circumstances. 

(8.) Neoplasms of the Bratn". — Adventitious growths are by no 
means of rare occurrence in the infantile brain. This is especially 



DISEASES. OF THE NERVOUS SYSTEM. 305 

true of tubercles, wliose effects are the more marked as tliey increase 
in size, and according to the rapidity of their growth. By the press- 
ure produced in this manner upon the surrounding cerebral parts, a 
general increase in bulk of the affected hemispheres takes place, and 
disturbances of the circulation are apt to ensue, which ultimately 
lead to cerebral oedema or effusion into the ventricles ; however, they 
are apt to occasion softening or small apoplexise in their immediate 
vicinity. The various forms of neoplasms, arranged in the order of 
their frequency, are — 

(a.) Tubercle. — The number of large tubercles in the brain is very 
limited, for usually they occur in twos or threes, and seldom more 
than five or six. The size varies according to the number, and 
usually fluctuates between a hazel and walnut. On the other hand, 
when a large number are found together, they are not apt to exceed 
the size of a pea. In form they always approximate more the round 
or oval, very rarely become agglomerated into irregtilar nodular 
masses, and, from this fact, it is supposed that tubercles probably 
embrace a certain space from the beginning, and do not subsequently 
become enlarged by external accretions. Tubercles have been found 
in all parts of the brain, still it cannot be denied that they are more 
frequently located in the gray substance than in the white. Hence, 
they are found either entirely at the periphery, or deep in the centre, 
where, as in the corpus striatum and optic thalami, much gray sub- 
stance exists. It is very rarely met with in the medulla oblongata, 
or in the septum or crura cerebri. Peripheral tubercles may be situ- 
ated so superficially that they touch the meninges and adhere to the 
dtira mater, and so be confounded with tubercles of the meninges, 
which, however, never occur in this manner. If the tubercle itself is 
examined accurately, it will be found to present no differences from 
the large cheesy tubercle of the bronchial glands or of the lungs. It 
consists of a yellow, lardaceous, tough, friable mass, which, under the 
microscope, exhibits no cell-formation, but only amorphous granules 
and masses, in short, nothing but detritus. The parts by which they 
are immediately surrounded are vascular, and the union between 
them and the cerebral tissue is not very intimate, for they may be 
entirely enucleated without any particular dexterity or trouble. 

The manner in which they originate is by no means clear, since 
only the fully-formed yellow cerebral tubercle is found, without any 
gray, crude, semi-transparent granules, such as it is possible to demon- 
strate in almost every tuberculous lung. It is true that MoJcitansJcy 
has occasionally found some portions of tubercles in this crude, jelly- 
like state, but he believes that the transformation must progress very 
rapidly. Usually tlie whole tubercle forms a homogeneous mass, 



306 DISEASES OF CHILDREN. 

witliout any differences in consistence or color ; still, occasicjnally, the 
commencement of softening may be detected, whereby the liquefied 
centre, or perhaps even the entire nodule, Avill represent a capsulated 
cavity with sanious purulent contents. Microscopically the purulent 
mass which occurs here is distinguished from genuine pus by the 
absence of all cell-like structure, and the presence of simple detritus. 
No cretaceous tubercle is ever found in children, for a period of many 
years is necessary for the calcification of large tubercular masses. 
The most common complication, and at the same time most common 
cause of death, is acute miliary tuberculosis of the meninges, with 
acute hydrocephalus, which appears to originate through a direct 
absorption of the primary tubercles. The next complication as to 
frequency is tuberculosis of the bronchial glands and lungs. The 
reason why large, yellow, cerebral tubercles are found oftener in chil- 
dren than in adults is, that the adventitious growth, which probably 
is congenital, or acquired immediately after bii-th, may remain latent 
for some time, even for several years, without displaying any well- 
marked symptoms, though death commonly occurs during childhood, 
and on this account this pathological condition is but exceptionally 
seen in the adult. Cerebral tubercles produce no symptoms that are 
not produced by other neoplasms of the brain, and, in order to avoid 
repetition, all the SAiiijitoms occurring with them will be described at 
the conclusion of this anatorao-pathological exjyose of their character. 

(b.) Carcinoma. — Carcinoma of the brain, like carcinoma in gen- 
eral, is of itself extremely rare in children. I have met with it twice 
only in infantile cadavers. According to the statements of all authors, 
the medullary cellular form, " fungus medullaris," is the predominat- 
ing variety; the hard fibrous cancer scarcely ever occurs. Cere- 
bral carcinoma either infiltrates the brain, gradually disappearing in 
the normal cerebral substance, or it is sharply defined, of a round or 
oval form, and in these cases may be entirely enucleated with great 
ease. Usually it is a mass of considerable dimensions, and exists 
only in one hemisphere ; still, instances are related where nodules of 
cancer were found scattered throughout the entire brain. They have 
no preference, as in the case of tubercle, for the gray substance. 
These carcinomata usually gvo\v very rapidly ; they become somewhat 
flattened when they have reached the vault of the cranium, and may 
even cause atrophy of the bone, and make their appearance on the 
scalp ; or they may grow along the optic nerves into the orbit and 
attack the bulbs. They are often primary in the brain, and remain 
isolated in it without simultaneously occurring in other organs. 

(c.) Entozoa. — A few solitary cases are reported of encysted worms 
havinor been found in the brains of children. Echinococcus has been 



DISEASES OF THE NERVOUS SYSTEM. 307 

found in the cerebral substance in the shape of large or small cysts. 
Cysticercus cellulosa occurs somewhat more frequently, and in most 
instances is at the same time present in large numbers in the muscles. 
The cysticercus, according to JRoJcitansTcy, is found almost exclusively 
in the gray substance, and preferably in the peripheral layers of the 
cerebral jDortion, where the cysts project above the level of the brain, 
and partly elevate the meninges. The animals may perish, and the 
cysts undergo calcareous degeneration, and a cretaceous substance will 
then be found enclosed in a capsule, and can be distinguished from 
cretefied tubercles with great difficulty. 

Symptoms. — It is one of the most inexplicable phenomena in pa- 
thology, that the symptoms of these neoplasms are by no means con- 
stant, and still more that, in a great number of cases, none at all are 
observed. Apparently perfectly healthy children are taken sick with 
acute hydrocephalus of the usual form, succumb to it in two or 
three weeks, and the autopsy reveals one or more large yellow 
tubercles in the brain, which may even be undergoing softening, hav- 
ing existed many months, perhaps years, without producing the slight- 
est symptom indicating their presence. In other cases, a prolonged 
and distinctly pronounced prodromatory stage is noticed, and the gen- 
eral signs of a chronic cerebral compression supervene. The child loses 
its appetite, vomits, and is attacked by unilateral or bilateral paralysis. 
The organs of sense become abolished, amaurosis, deafness, violent 
headache, convulsions, and contractions of the muscles, come on, and 
then the symptoms of meningitis usually terminate the sufferer's life. 
In most of the cases affected with the various kinds of carcinoma, 
there is intense headache, quickly followed by incessant restlessness, 
stuttering, weakness of the organs of sense, movements resembling 
St. Vitus's dance, onanism, convulsions, sleeplessness, paralysis, and 
exhaustion. In encysted entozoa, epilepsy, and chorea in particular, 
is frequently observed, and, in addition, the symptoms just described. 
The diagnosis of probable cysticercus can only be formed when, with 
the existing cerebral symptoms, the cysts of this entozoa can at the 
same time be found in the muscles, eye, and other parts of the body. 
Neoplasms of the brain are beyond the reach of therapeutics. They 
can, at the utmost, call for a symptomatic treatment only. 

(9.) CoNGE^^TAL Malformations. — Besides congenital hydro- 
cephalus and hernia cerebri already spoken of, a few other arrests of 
development occur, which are of interest to anatomy and to embryol- 
ogy only, as most of them are mere monstrosities. 

In this class we find acephalia^ or brainless and headless mon- 
sters. This condition is generally accompanied by spina bifida, ectopia 
of the heart, absence of the lungs and abdominal viscera, and distorted 



30S DISEASES OF CHILDREN. 

extremities. There may, however, be only a deficiency of the hrain^ 
which may exist either in the longitudinal or transverse diameter. 
Thus hemicephalia may exist of various grades ; almost the entire 
brain may be wanting, from the small remnants of which the cranial 
nerves originate. The hemispheres may be wanting, with the ex- 
ception of a small portion at the base. Conjointly with this, the 
cranial bones are defective, or of a rudimentary formation, and the me- 
ninges primarily distended into a bladder containing water, but which, 
having burst very early, hangs in atrophic folds over the shapeless 
cerebral masses. Again, only a small portion of the brain may be 
wanting — the anterior lobes, for example, and olfactory bulbs, the 
optic thalami and optic nerves, pons Varolii, etc. Along with this, a 
corresponding malformation of that part of the face destined for the 
reception of these absent structures exists. The cranial bones in these 
cases, though small, may yet exist. The most striking of all defects 
in the longitudinal diameter is the single cerebrum^ combined with 
cyclopia, and absence or deformity of the face. Next is a coalescence 
of the optici thalami and corpora striata ; or still again, an absence 
of the commissures, thus splitting the brain by this condition of 
the parts. In these cases the formation of the bony case may have 
taken place normally; but idiocy and bodily defects always exist. 
Again, the brain, though existing, may be very small^ but in all 
other respects perfectly formed; microcephalia. This condition oc- 
curs independently of that in which partial absence of some part 
exists. The vertex in these cases is low, the forehead flat, and the 
entire head pointed. Children so affected are capable of life and 
development, and, singularly enough, are not tardy in their mental 
development. 

Excessive growth of the brain is extremely rare, and the nu- 
merous splittings of the lobes which here and there occur are to be 
looked upon rather as anomahes of form than excessive formations. 

B.— DISEASES OF THE SPINAL CORD AND MEMBRANES. 

(1.) SprsTALMEiiaNGiTis AND Mtelitis. — ^The diseases of the spinal 
marrow are still in a state of obscurity, and all that is positively known 
of them could be stated in a few lines, if we were only to confine our- 
selves to the distinctly demonstrative anatomo-pathological alterations. 
First of all, as regards the much-abused hyperaemia ; oSS. post-mortem 
appearances must be excluded as spurious where the cadaver was 
not placed upon its face immediately after death, and the autopsy 
was performed later than twenty-four hours after life terminated. 
Without this precaution there will be found in every case, even in the 



DISEASES OF THE NERVOUS SYSTEM. 



309 



most normal, extensive post-mortem hypostasis, imbibition of the 
coloring matter of the blood, and putrid softening, by which it becomes 
totally impossible to establish the previous existence of any actual 
disease in the medulla spinalis. Although the anatomo-pathological 
condition is different in kind, still inflammation of the spinal cord and 
its membranes may be comprised in one group of symptoms, for the 
phenomena in both processes are almost identical, and hence a differ- 
ential diagnosis becomes extremely problematical. 

Pathological Anatomy. — The sac that is formed by the dura matei 
does not completely fill out the canal of the spinal column, but is 
secured there by adipose tissue, which accumulates more toward the 
vertebral laminge, anteriorly against the vertebral bodies by loose cel- 
lular tissue, and all around by venous plexuses. This sac of the dura 
mater, on its inner side, is firmly united with the external lamella of 
the arachnoid ; while the internal lamella of the latter hangs loosely, 
together with the pia mater. Between these external and internal 
plates or lamellae, is contained the cerebro-spinal fluid, which mingles 
with that of the meninges and ventricles of the brain, and even in 
small children may amount to a drachm. The pia mater of the cord is 
richer in vessels than that of the brain, and in the new-born child can 
readily be pulled off. Having thus briefly recapitulated the normal 
condition of the spinal meninges, we may proceed to the investigation 
of the character of the hyperaemia and of the hgemorrhage. In young 
children the cerebral arachnoid and pia mater, and the veins withia the 
spinal canal, are always plethoric ; in fact, the vessels are so full that, 
even when the precaution is taken of turning the body on its face im- 
mediately after death, extravasations are not of unfrequent occurrence. 
These pathological phenomena were first explained by Weber, of Kiel. 
It is not always easy to determine whether the blood found external 
to the dura mater was extravasated during life, or whether the blood 
was poured out upon the dura mater, from veins that have been sev- 
ered during the removal of the vertebral lamin:©. The best means of 
guarding against an error is not to attempt the removal of very long 
sections of the vertebral laminae at one time, but to remove small 
portions, at different places, and then allow a feeble stream of water 
to play upon the exposed dura mater. The blood exuded from the 
veins after death is entirely washed away in this manner, while that 
extravasated during life is always somewhat coagulated, and adheres 
rather firmly to the dura mater. These haemorrhages are most fre- 
quently found in the cervical and lumbar regions, sometimes extend- 
ing but a short distance, or lining the whole spinal canal, forming a 
complete sheath of coagulated blood. Small extravasations are some- 
times seen more distinctly upon the disarticulated vertebral laminae 
21 



310 DISEASES OF CHILDREN. 

than upon the dura mater, and for that reason the inner surface of 
the former must always be thoroughly examined. Tlie same kind of 
haemorrhages which occur externally to the dura mater are also met 
with in the sac between the dura mater and arachnoid, or the latter 
and pia mater. Here also the amount of the extravasations varies 
between a pin's head and such a quantity that the whole cord is sur- 
rounded by blood. It is less easy here for one to fall into an error, in 
supposing that this fluid has originated during the autopsy, because 
the dura mater has no large veins which might have been severed. 
Aside from these hsemorrhages which, conjointly with the consider- 
ation of inflammation, have been disposed of, as the highest grade of 
hyperasmia, true exudations also occur upon and beneath the meninges. 
In the loose cellular tissue between the dura mater and the bony spinal 
canal some serum is always found, even in the normal condition ; it 
may, however, become considerably augmented, and, like a gelatinous 
mass, cover large regions of dura mater as well as remain adherent to 
the inner surface of the disarticulated laminse. In older children, 
after injuries to the spine, or in spondylitis, a visible opacity and 
thickening of this membrane are also found, along with a deposit of a 
plastic fibrinous character. In all children a moderate quantity of 
spinal fluid is found on opening into the dura mater, which normally is 
of a pale-yellow color and perfectly clear, but which, in afifections of 
the arachnoid and pia mater, becomes opaque, flocculent, and bloody. 
Bloody discolored spinal fluid is especially found in children dying 
from pysemia during the prevalence of an epidemic of puerperal fever. 
The fluid exudations are alwa^'s found in the most dependent part, 
according to the position of the bod}'. In rare instances, a fibrinous 
deposit is found upon the dura mater conjointly with the flocculent 
cerebro-spinal fluid, w^iich, like the purulent meningitis within the 
cranium, may become of a purulent nature. Usually the spinal cord 
itself, in these morbid alterations of its membranes, is softened and 
eroded, so that it is difiicult, in examining the spinal cord of a child, to 
diagnosticate a softening or sclerosis merely by the resistance which 
a scalpel meets, for the spinal cord, in general, is so soft that the 
slightest force will di\dde it. \Miere these morbid changes have taken 
place, there, as a rule, red softening is observed in some part of the 
cord itself. The most striking lesions of the cord are found in 
Pott's disease, wdiere an angular curving of the cord has taken place 
in consequence of a similar curving of the spinal column from destruc- 
tion of the bodies of the vertebras. The cord at the angular spot is 
dense, flattened, and somewhat yellow, or more reddish-colored than 
elsewhere ; sometimes complete solution of continuity is observed. 
Symptoms, — In the new-born child, hasmorrhages and inflamma 



DISEASES OF THE NERVOUS SYSTEM. g^ 

tions witliin the spinal canal furnish no characteristic symptoms, for 
the tonic and clonic spasms then observed occur even more frequently 
without any demonstrable lesions of the spinal cord. The symptoms 
belonging to these conditions can be studied to better advantage in 
children with spina bifida, the sac of which is ruptured, or in a gan- 
grenous condition. Such children are attacked by intermittent spasms 
of the dorsal muscles, which may be transient, and only of slight de- 
gree. Sometimes, however, they take the form of the most violent 
and protracted opisthotonos. Touching the spinal column in these 
patients always causes excessive pain, and induces new spasms, and, 
for this reason, it is well to keep them constantly upon the side. Severe 
pains are also produced by touching either of the lower extremities 
before they become paralyzed. Motion aggravates the pain exces- 
sively, and induces new spasms. Finally, paralysis of the lower and 
then of the upper extremities supervenes, occasionally alternating with 
spasmodic convulsions, and death ensues, after a few days, from tris- 
mus and tetanus. In older children, well-pronounced spinal symptoms 
are distinctly seen in caries of the spinal column, and as sequelae of 
scarlet and typhus fever, where complete paralysis of the lower ex- 
tremities remains. The patients describe very distinctly a sensation 
as if the limbs were covered with fur, or of ants creeping upon them ; 
the sensibility of the integument is diminished ; severe pain, however, 
is complained of, if much force be applied. Sometimes convulsive 
twitchings take place, soon followed by total paralysis. The process 
at first runs a febrile course, i. e., with a frequent pulse, hot skin, noticed 
most markedly on the back. This fever soon subsides, but the paraly- 
sis continues for many months, and perhaps during life. The rarer 
phenomena noticed in this malady are : disturbances of the sensibility 
of the skin, difficult deglutition, palpitation of the heart, attacks of 
dyspnoea, singultus, priapism, etc. In this connection, the paralysis 
and convulsions are briefly considered, because the symptoms are often 
found to exist without any demonstrable lesion of the spinal cord, and 
their practical importance will be considered farther on in a special 
section. Inflammation of the spinal cord occurs almost always in a 
sporadic form ; stiU, according to West^ it has been observed as an 
epidemic in France, between the years 1843 and 1844, and lately in 
the hospitals and workshops of Ireland. Although very decided 
quantities of serous efi"usions were found between the meninges, still 
the cord was rarely and but very little altered. The disease ran a 
very acute course, and terminated fatally in from one to four days. 
In regard to the differential diagnosis between inflammation of the 
spinal cord and that of the membranes, a rule has been established 
that the first runs a chronic course, without any febrile movement, 



312 DISEASES OF CHILDREN. 

and with a predominating paralysis, while the latter begins with active 
symptoms ; fever and general convulsions and paralysis subsequently 
become superadded. As has already been observed, both diseases, 
more or less developed, run then- course together, and it is therefore 
impossible, and, in fact, useless, to seek for differential signs. 

Therapeutics. — An antiphlogistic, methodical treatment can be 
applicable in the rarest instances only, for the reason that the patients 
are too young, or, if advanced in years, have been so reduced by the 
preceding affections w^hich are the fruitful cause of disease of the cord, 
such as spondylarthrocace, and scarlet or typhus fevers, that they do not 
tolerate an antiphlogistic treatment. In the early stage of the dis- 
ease, fever and convulsions are best treated by small doses of calomel. 
An infusion of arnica-leaves may be given when the first violent 
symptoms have been palliated, but it is not possible to say that any 
beneficial effect will be derived from it. The paralysis that usually 
remains offers no very unfavorable prognosis, for, wdth the increase of 
bodily strength, improvement, if not complete recovery, may take 
place. Cold douches to the back, and the administration of strych- 
nine, are important adjuvants; with the last remedy, however, we 
must never exceed one-eighth, or, at the most, one-sixth of a grain pro 
die, as otherwise symptoms of sudden poisonmg are apt to be in- 
duced. The bladder should be constantly looked after, and the cathe- 
ter used, if its contents are not voided for more than twelve hours. 

(2.) Spina Bifida. Htdeorrhachia. [Hiatus Spmalls Gongen- 
ittcs.)—3y hydrorrhachitis is understood a congenital tumor on the 
vertebral column, generally situated in the sacral portion, and pro- 
duced by a protrusion of the meninges of the cord through a bony 
aperture in the spinal canal. 

Pathological Anatomy. — Several degrees of this deformity may 
exist, and are known as follows : The defect may be confined to a por- 
tion, or include the whole canal. A total splitting of the vertebral 
colmnn is only met with in monsters, hemicephalia, etc., and there- 
fore does not come within the domain of clinical investigation ; but 
defective formation of indi\adual vertebrae does not produce a condition 
incompatible with life, and must be more carefully studied. Here 
also we have marked gradations in the extent of the malformation. 
In the mildest grade of the disease the laminae are imperfectly devel- 
oped, or, being normal, the spinous processes are not united, and ex- 
hibit a narrow fissure between them. Again, the -spinous processes 
may be entirely absent, or the bodies of the vertebra are separated, 
and a wide fissure is seen to extend through the entire thickness of 
the spinal column. Lastly, in the extreme cases, the fissures are still 
wider, and several of the vertebrae are in a rudimentary state. If the 



DISEASES OF THE NERVOUS SYSTEM. 31 3 

tumor itself be examined, the sac will be found to be continuous with 
the dura mater and arachnoid membranes of the cord ; the integument 
covering the tumor is of a normal character, or atrophic, and semi- 
transparent, or it may be absent. In the latter case doubtless it was 
ruptured in utero, or during labor, and is found hanging in loose folds 
about the fissure. Where the membranes have remained entire, the 
tumor, during life, is tolerably tense, and fluctuates, while in the 
cadaver it is collapsed and flabby. Its contents are the liq. cerebro- 
spinalis. It varies in size from that of one scarcely perceptible to the 
touch, to that of a tumor the size of a hen's egg ; is usually situated in 
the lumbar region, but may extend throughout the entire column. 
The cord itself may be normal, or, if the tumor be situated low down 
in the lumbar region, it may be spread out tuft-like upon the inner 
wall of the sac. 

Symptoms. — These have been pretty well considered objectively. 
In shape, the tumor is oval or pyriform, sometimes pediculated ; the 
integumentary covering is discolored and red ; distinct radiating cica- 
trices are often observed on the flattened tumor, probably due to la- 
ceration of the sac, and subsequent union during foetal life. By press- 
ure, the tumor becomes somewhat smaller; if a second sac exists, or 
when it is complicated with a congenital external hydrocephalus, the 
latter will become more tense. Pressure upon the tumor is extremely 
painful, and often produces tetanic spasms. In large tumors with atro- 
phic coverings, movements synchronous with the respirations may also 
be distinguished, the tumor increasing during inspiration, and diminish- 
ing dming expiration. On examining the margins of the tumor, the 
fissure in the vertebrse, with its upper and lower angle, and leaf-like 
dilatation at the centre, will readily be detected. The subjects are 
mostly born alive, but very rarely live longer than a few days. The 
tumor often bursts during delivery, sometimes becomes gangrenous 
without rupturing ; the integument rarely retains a normal character, 
and subsequently becomes thickened. When air enters the tumor, or 
when the latter becomes gangrenous and bursts, purulent meningitis 
is apt to supervene, and will quickly terminate fatally. If a small 
tumor exists, and the integuraent remains intact, the patients may 
thrive ; but paralysis of the bladder, rectum, and of the lower extremi- 
ties, is apt to ensue, and result in death. Yet, cases are reported of 
individuals, thus afi'ected, enjopng comparatively good health for 
twenty or thirty years. In the higher grades, the disease rarely exists 
by itself, but is complicated with congenital hydrocephalus, ectopia of 
the bladder, of the heart, club-feet, etc. 

Chaussier has shown, by the statistics of the Maternite, at Paris, 
that one case of spina bifida occurs in one thousand births. 



314 DISEASES OF CHILDREN. 

These tumors are not easily confounded with any other variety of 
tumor, as the vertebral laminae may be felt to be ununited in every 
true case of spina bifida. Rare instances of congenital hernia dor- 
saHs, cysts, adipose and honey-like tumors (Honiggeschwiilsten), are 
reported as curiosities in medical literature, as having been met with 
upon the spinal column, and calculated to mislead one into regarding 
them as cases of hydrorrhachis. The extraordinarily rare condition of 
intrafoetatio, a foetus within a foetus, where a large formless tumor with 
a few bones is found situated upon the sacrum, has naturally no anal- 
ogy whatever to the condition under consideration. 

Therapeutics. — Surgeons have tried countless varieties of methods 
with the hope of bringing about a diminution of the tumor, and clos- 
ure of the spinal canal. The almost invariable failure of all surgical 
procedures is due to the fact that the inner wall of the sac is formed 
by the spinal arachnoid membrane, and that any injury of this mem- 
brane is apt to produce meningitis, which cannot be limited to the 
sac. The tumor has been repeatedly punctured with exploring tro- 
cars and pierced with needles after forming valvular openings in the 
integument. Lately Gaupp presented a boy seven years old, who 
had a hydrorrhachis the size of a child's head, w^hich he had cured in the 
first few weeks of infantile Hfe by puncturing it eight times. After the 
first puncture, the fissure of the vertebrse could be distinctly felt, but 
the gap rapidly diminished, and finally closure took place in ten 
weeks. All the parts constituting the vertebrge are now present in 
this boy, but the spinous processes are somewhat flattened. Excision, 
with the subsequent use of compression by quills or small wooden rods, 
has been tried. Chassaignac treated these cases by puncture and 
injecting iodine, as in a hydrocele, and the pediculated variety has 
been tied off. Finally, constant, steady pressure upon the tumor by a 
hair pillow has been tried, but, although this method caused great pain 
and convulsive twitchings, it did not effect a single cure. All experi- 
menters have been obliged to acknowledge that their efforts have 
failed, nay, still more, that meningitic symptoms, which are always 
followed by death, came on immediately after the operation. Though 
the prognosis of hj'^drorrhachis is at best very unfavorable, most chil- 
dren dying even without operation, still, owing to the rarity of this 
condition, statistics upon this point are scarce, and it is therefore diffi- 
cult to determine which of the two courses it is best to pursue. 

The most rational treatment, it seems to me, is to protect the sac 
from all kinds of injury and pressure, by a soft, cup-shaped pad 
which will only rest upon its margin, and which is secured to the 
body by elastic straps. If the hydrorrhachis is complicated with con- 
genital hydrocephalus, as is frequently the case, then no other means 



DISEASES OF THE NERVOUS SYSTEM, 3^5 

should be adopted than that just described, for every diminution and 
compression of the tumor causes tension within the head. 

Q,.— DISTURB ANCES IN TEE NERVOUS FUNCTIONS. 

A number of functional diseases of the nervous system are prob- 
ably only symptomatic of morbid alterations of the brain and spinal 
cord, if we may judge from the analogy between their individual 
phenomena and those of diseases whose pathological alterations are 
known. The corresponding morphological or chemical alterations of 
the nervous centres, however, have not yet been demonstrated, 
which is attended with great difficulty on account of the circum- 
stance that most of these nervous diseases terminate favorably, and 
post-mortem evidence, therefore, is rarely attainable. As the demon- 
stration of the cerebral morbid processes has not yet been accom- 
plished, we have no other resource but to assume that the brain and 
spinal cord are in a normal condition, and to dehneate symptomatically 
the individual phenomena, with their acquired denominations. 

(1.) Eclampsia Infantum (Convulsions). — Convulsions in chil- 
dren have long been well known, even to the laity, and form an im- 
portant class in the diseases of children. They are known by many 
names : tremor of the head, silent tremor, silent wail, shudderings, 
spasms, and cramps. These aU refer to the same disease, and are 
characterized by general or partial clonic twitchings of the muscles, 
and generally caused by some other febrile disease. Consciousness is 
almost or wholly gone, particularly when the convulsions are general. 
The single attack cannot be distinguished from an epileptic attack, 
but epilepsy is characterized by its chronic course and unexpected 
recxirrence, and fi-eedom from fever. From chorea, eclampsia is dis- 
tinguished by the fact that the muscular contractions in the former 
continue incessantly throughout the day, and even for several 
weeks before the affection is relieved, and that the general condition 
is not affected by it. As regards the period of life at which convul- 
sions most frequently occur, childhood, up to the completion of the 
first dentition, is the most common ; still, even older children, who at 
an earlier age have suffered from eclampsia, are attacked with violen£ 
convulsions at the commencement of an acute attack of an exan- 
thema, even of an angina, or from an overloaded stomach. The 
milder, partial tremors in most instances last for several days, and 
reoccur frequently, especially in young children, in consequence of dis- 
tvirbed digestion. The general convulsion, to which alone the term 
eclampsia ought to be restricted, is not a protracted affection, it being 
either terminated in a single attack, or, after several paroxysms, 
always at certain intervals. 



316 DISEASES OF CHILDREN. 

The following symptoms are those generally seen in children 
under one year, who are attacked by the milder form : The child 
sleeps with half-closed eyelids, the ball of the eye is turned upward, 
and nothing but the white sclerotica can be seen through the palpebral 
fissure. The muscles of the face, during sleep, are contracted in vari- 
ous manners, whereby it may seem as if the child were smihng (risus 
sardonicus), or, as some astute nurses say, "The child is playing with 
the angels." The breathing is rapid and irregular, sometimes super- 
ficial, and sometimes again accompanied by deep sighs ; the limbs 
tremble and twitch, the hands are clinched, and the lower extremi- 
ties, with the toes sprawling, are contracted against the body. From 
a restless sleep of this kind, the little one now awakes, frightened, 
with a cry, and manifests its discomfort by kicking, curving and 
twisting of the whole body. After expelling some intestinal gas, 
often with stools of green mucus, and very offensive, and sometimes 
vomiting, rest and general perspiration, as a rule, ensue, but often 
restlessness remains for some time. This condition may last many 
days, and recur several times a day at short intervals. Most of the 
children become feverish, and, owing to defective nutrition and con- 
stant muscular action, the face becomes emaciated and pointed. The 
more serious form, the true eclampsia infantum, manifests itself as 
follows : Generally the severer symptoms do not come on at the very 
beginning with the greatest intensity, but are usually preceded by 
the class of symptoms already detailed, which also vary according to 
the age of the child. Obedient, good-natured children become wil- 
ful, morose, choleric, are apt to be attacked by muscular tAvntching 
during sleep, gnash their teeth, and wake up frightened, with an 
anxious cry. The eyeballs are rolled upward, the lids are not com- 
pletely closed, the angles of the mouth are contracted into an unpleas- 
ant risus sardonicus, and the general state of the system is always 
somewhat perturbed. The patients are suddenly attacked by the 
paroxysm, both when asleep and when awake, and it is impossible to 
distinguish it from an epileptic fit. 

They suddenly become completely unconscious ; squinting or an 
unsteady rolling of the eyeballs sometimes comes on, butusually the 
eyes are fixed and staring. The facial muscles are attacked by the 
most varying t-\vitchings ; sometimes a smile plays over the face, 
and sometimes again an expression of anger or displeasiu-e, which, 
conjointly with the exposed teeth, gives the patients an appear- 
ance of beastly ferocity. The jaws perform various acts, such as 
masticating, snapping, etc., accompanied by gnashing of the teeth. 
Fluids poured into the mouth excite very imperfect acts of degluti- 
tion, and the greater part flows out again. By this time the con\'ul- 



DISEASES OF THE NERVOUS SYSTEM. 317 

sions have involved almost all the muscles of the body. The muscles 
of the back are in a state of tonic contraction, or are affected with te- 
tanic twitchings ; the extremities perform the acts of striking, thrust- 
ing, or twisting ; the respiration becomes very irregular, and, in con- 
sequence of spasm of the glottis, may stop altogether. After a few 
whistling inspirations, the breathing is suddenly suspended, and death 
may ensue in a few minutes, if the spasm does not subside. As an 
effect of the impeded respiration, we may have bleeding from the mu- 
cous membrane of the mouth and nose ; but the bloody froth that is 
usually seen between the lips is oftener due to injuries of the tongue 
or mucous membrane, which frequently occur during the snapping, 
biting movements of the jaws, or may be produced by the numerous 
attempts of the relatives to prevent them. The heart contracts very 
rapidly, but not unrhythmically. The stools and urine frequently pass 
off involuntarily. The temperature of the skin on the body is nor- 
mal, on the extremities is apt to be diminished, and, toward the end 
of the attack, a perspiration usually breaks out. The sensibility of 
the skin is so completely abolished that the patients cannot be roused 
to consciousness by any means, not even the most painful irritants, 
and they often hurt themselves during their convulsive movements. 

The entire train of symptoms here presented is hardly ever ob- 
sei'ved in one attack ; some of them may be absent, without making 
the paroxysm a mild or an incomplete one. 

Such an eclamptic fit lasts for only a few seconds, or, at the most, 
minutes ; paroxysms that last longer than this are due to serious or- 
ganic lesions of the brain, and should be distinguished from eclampsia. 
A similar condition ensues after the termination of the convulsions as 
after an epileptic fit. The patients are semi-comatose and exhausted, 
the fever increases, the eyes become injected, cerebral symptoms su- 
pervene, the appetite is gone, and nurslings will not even take the 
breast. 

Formerly, when the antiphlogistic treatment was much more liber- 
ally employed in children, a distinction between eclampsia cum hyper- 
asmia and cum ansemia was made, and the therapeutic measures were 
accordingly distinct. In the former, phlebotomy and subsequently 
leeches were used ; in the latter, these remedies were not employed. 
Now, when abstractions of blood are not so much in favor, this dis- 
tinction is of less value ; in fact, we have learned that pale, anasmic 
children are as liable to be attacked by convulsions as robust and 
plethoric ones. 

Theoretically we distinguish, in addition, (1), an idiopathic, i, e., 
an eclampsia issuing directly from the brain; and (2), a deuteropatJiic, 
i. e., one reflected to the brain from a diseased organ. Practically, this 



318 DISEASES OF CHILDREN. 

distinction is often impossible, and we remain uncertain, even after a 
long observation of the case, which kind of eclampsia we have to deal 
with. The autopsy alone can clear up this obscurity. 

Etiology. — (1.) Idiopathic eclampsia may be produced by me- 
chanical compression of the head during delivery, by pathologi- 
cally demonstrable alterations in the brain, particularly tuberculosis, 
or by nutriments and medicines, as spirituous liquids and narcotics, act- 
ing directly upon the brain, and by insolation. Children with a soft 
occiput are more disposed to convulsions than others, a detailed 
description of which will follow in the article on racliitis ; they may, 
however, also originate from direct cerebral irritation, for example, 
from pressure from without. Mental over-exertion is also advanced 
as a cause, but it is certainly the rarest of aU the causes. Violent 
fright, great anxiety, and vehement outbursts of anger, are perhaps 
the most probable ones. 

(2.) Deuteropathic or sympathetic eclampjsia is by far the most 
frequent form, and the intestinal canal the source from which reflex 
convulsions oftenest arise. The intense irritability of the primse \\2e in 
all ages of life furnishes the greatest opportunities for them. They 
may even be occasioned in the first few days after birth, by the re- 
tention of the meconium, but at this age there may always be a sus- 
picion of a mechanical injury to the head during the act of dehvery. 

There is also a peculiar, chemical, unexplained cause, namely, the 
milk of a Avet-nurse, who, shortly before, had been subjected to some 
mental excitement. Instances have been reported of children, pre- 
viously perfectly healthy, having been attacked, soon after taking such 
milk, by short but violent convulsions, which terminated in sudden 
death ; and at the autopsy no cause whatever could be found. These 
cases, however, are so rare, in comparison with the many cases in 
which such mental excitement on the part of the wet-nurse is not fol- 
lowed by such results, that this supposed cause has been justly doubted. 
On the other hand, however, those evil efi"ects, produced by an artificial 
nutrition, from which intestinal catarrh follows, and in the train of 
which milder and more serious cerebral irritation must sooner or later 
ensue, cannot be doubted. These have been seen to occur with their 
greatest intensity at the period of weaning. Such children suffer 
first fi-om flatulence and colic, afterward are attacked by a diarrhoea of 
green-colored and fetid stools, and vomiting ; they become very rest- 
less and feverish, and, finalh% con\Talsions ensue. In other cases the 
latter are not preceded by diarrhoea, but, on the contrary, by consti- 
pation and loss of appetite. In older children, indigestion and the 
irritation produced by worms merit particular consideration. 

An additional cause, and one that deserves to be well attended to, 



DISEASES OF THE NERVOUS SYSTEM. 319 

is found in the eruption of the teeth. This process is generally com- 
plicated with digestive disturbances, and hence these may be regarded 
as the prime cause of the convulsions. But there occur cases in which 
the digestion is entirely undisturbed, and the reflex convulsions there- 
fore have to be explained by other causes than the inflammation of 
the mucous membrane alone. To authorize the opinion that dentition 
is the cause in any case, the child must be in one of the five periods 
of dentition. The mouth will then be reddened and hot, the mucus 
is often secreted in less quantities than in the normal state, one or the 
other cheek is dark red in color, it is very restless, and bites at 
every thing that comes near the mouth, even the nipple of the wet- 
nurse. Eclampsia, originating from dental irritation, belongs to the 
serious forms, and often leaves behind it partial paralysis and im- 
becility. 

A third principal cavise of convulsions is the breaking out of an 
acute febrile disease^ particularly an acute exanthema, where the convul- 
sions in children seem to be analogous to the chill of fever in adults. 
These eclampsias are attended by very little danger, are of short dura- 
tion, and rarely followed by pernicious consequences. This cause 
may be conjectured with tolerable certainty when eruptive diseases, 
which the child has not yet experienced, happen to prevail epidemic- 
ally, and the prodromata of such an exanthema have manifested them- 
selves. If it be measles, there will be cough, sneezing, and lachryma- 
tion. If scarlatina, there will be angina, with difficult deglutition. If 
small-pox, persistent headache, pain in the back, and violent fever. 
Often, however, no jDrodromata at all are observed, and only the course 
of the disease explains the cause of the convulsions. Among the 
acute diseases to be mentioned, besides the acute exanthemata, are 
pneumonia, intermittent fever, and fever following injuries and opera- 
tions and simple anginse. A male child was once placed under my 
care who suffered two or three times every year from intense angina, 
and in the first day of the illness an eclamptic fit invariably took 
place which was not distinguishable from epilepsy. I finally extirpated 
ooth tonsils, and the eclampsia, or, as the afflicted parents supposed, 
the epilepsy, has not recurred during the last two years. 

Finally, cases are also reported, especially by the older wi'iters, of 
convulsions said to have originated after the rapid healing oiprofusely- 
discharging erujytions. Some remarks have already been made, w^hen 
on the treatment of acute hydrocephalus, concerning the connection be- 
tween the latter and humid eruptions of the head, and it cannot be de- 
nied that, in the rajiid healing of external suppurations, the internal 
organs, and consequently the brain, are subject to the danger of becoming 
inflamed. On the other hand, we must also acknowledge the fa^t that 



320 DISEASES OF CHILDREN. 

many hundreds of cases of impetigo disappear rapidly, either spontane* 
ously or by treatment, yet the chikken remain as well as before. 

The inheritabillty plays a certain role in the etiology of this dis- 
ease. The parents, as a rule, have suffered from this affection, and the 
mothers, in particular, are hysterical and repeatedly afflicted with hy- 
peraesthesia. JBouchut relates the history of a family of ten persons, 
all of whom suffered in their youth from convulsions. One girl of this 
family married, gave birth to ten children, and nine of these suffered 
from eclampsia. 

Course, Termination, and Progress. — Partial muscular contractions, 
the so-called convulsions (Fraisen), may be protracted for many days 
during an acute affection, without very greatly augmenting its danger. 
The genuine eclampsiae, however, are mostly completed with a single 
attack, and the very first eclamptic fit may terminate fatally, or the 
morbid process that caused it may become fully developed on th§ 
following day, thus remo\'ing the cause for sympathetic convulsions. 
Those induced by gastric irritation are relieved by vomiting, expulsion 
of flatulence, or diarrhoeal stools ; those depending upon toxaemic 
causes never return after the acute exanthema, scarlatina, roseola, or 
variola has once broken out. 

As has been observed on a former occasion, this kind of convul- 
sions is seldom fatal ; nevertheless, it always gives reason for the 
conjecture that the disease following will be strongly developed and 
run its course with violent sjonptoms. In general, the rule may hold 
good. The yoimger the child the more critical will be the prognosis. 

According to my experience, those convulsions due to dentition 
and comjDlicated with intestinal affections — excepting those, in fact, de- 
pending upon actual cerebral disease, which almost always lead to 
death — offer the worst prognosis. Such children die either in a fit or 
are attacked by h3'drocephaloid disease and perish. Others live inva- 
lids from permanent brain-injury resulting from the convulsive disease. 
Almost all squinting children, in whom the strabismus cannot be re- 
ferred directly to a \dsible defect of the cornea and lens, have suffered 
from eclampsia in the first years of life. In addition, loss of either one 
or more of the senses, amaurosis or deafness, imbecility in various de- 
grees, chronic hydrocephalus, and general or partial muscular paralysis, 
may result from this distressing malady. 

Therapeutics. — We must first discriminate between the partial 
muscular twitchings (the Fraisen) and the general epileptiform con- 
vulsions, the true eclampsia infantum. The treatment, moreover, varies 
according to the age and strength of the child, and it is absolutely 
necessary to institute a thorough examination in order to get upon the 
right track as to the cause of the disease. In this examination the 



DISEASES OF THE NERVOUS SYSTEM. 321 

physician must not content himself with the assertions of the rela- 
tives, but should personally examine the entire body of the child. 
For, a splinter in the sole of the foot, between the toes, a foreign 
body in the nostrils, or in the external ear, may also be the exciting 
cause, the removal of which will rapidly cure the disease. 

In the paroxysm itself the physician can very seldom render any 
material aid, for the reason that by the time he reaches the house 
the convulsions have almost invariably passed off, and he has to 
confine his services to imparting comprehensive instructions with 
the view of preventing the recurrence of the attacks. The first 
thing to be done is always to undress the child as quickly as possible, 
so that no constricting bands or skirts may additionally impede the 
respiration and circulation. Next the child, with the head slightly 
elevated, is laid upon a large bed, or on the floor, when the con- 
vulsions are so violent that there is danger of injury to the extremi- 
ties against the sides of the bed or of its falling off. That such 
children are not to be left alone is self-evident. By sprinkling the 
face and exposed chest with cold water we may succeed in inducing 
deep, spasmodic inspirations, by which the danger of suft'ocation at 
least is lessened. No other striking abortive effect, however, is 
usually accomj^lished by this procedure. 

[There are eclampsise which require active treatment, and which 
cannot be disposed of with a mere placebo, because of the danger 
of congestion of the brain from the continuance and severity of the 
convulsions. I have repeatedly had occasion to treat the children 
of two remarkably neurotic families for recurring attacks of con- 
vulsions, in whom the spasms would last for hours if not interfered 
with. The flushing of the face, the contortions of the muscles, and 
the violent spasmodic contractions of the limbs endangered the life 
of the child by asphyxia and congestion of the brain, and called for 
prompt treatment. Formerly, I used in such cases chloroform by 
inhalation, dropping ten to fifteen drops of chloroform on a hand- 
kerchief and allowing the child to inhale it, adding a few drops, 
from time to time, if necessary, until the convulsions were subju- 
gated. In very severe cases it required one and even two hours 
to do that. Lately, I have been in the habit of using chloral hy- 
drate (in solution) in enemata, injecting 3j to 3 ss., for a child 
one year old, repeating the injection in a quarter of an hour, if 
necessary, and derived more prompt results from this remedy than 
from the chloroform inhalation. I can speak with the utmost satis- 
faction of this procedure.] 

Venesection, suggested by some therapeutists in this disease, is, 
aside from all other objections, inadmissible, for the reason that it is 



322 DISEASES OF CHILDREN. 

not possible to perform it during the paroxysm, or at least not with- 
out uncertainty and danger, for, when a vein has finally been opened, 
the aperture is immediately closed again by the contraction of the 
arras and displacement of the wound in the cutis, and the flow of 
blood must necessarily be arrested. I may mention here the sug- 
gestion thrown out by Grantham^ to constrict the skull in children 
whose fontanels are not yet ossified, by firmly bandaging it. I have 
tried this bandaging of the scalp in two cases, but have derived no 
benefit in either ; on the contrary, such an amount of restlessness 
was produced, when continued for the long time recommended by 
the aforesaid author, as a prophylactic, that after a few days it had 
to be abandoned altogether. 

As regards the benefit to be derived from remedies after the at- 
tacks have passed, we have to look for that mainly in derivatives. 
Sinapisms, or, in infants, leaven is applied to the calves of the 
legs, or these parts are rubbed with mustard spiritus, by which in- 
tense redness is almost instantaneously produced. When there is 
the least suspicion of the existence of gastric irritation, a derivative 
from the intestinal canal should also be administered. This should 
only be omitted in children who before and during the fits had had 
diarrhoea, and had expelled large quantities of flatus. To older chil- 
dren, who shortly before the paroxysm had taken a considerable 
amount of nutriment, it is best to give a proper emetic of, for exam- 
ple, tart, stibiat. gr. i., dissolved in a strong infusion of ipecacuanha, 
by which the entire contents of the stomach are soon evacuated. 
But, where no probable overfeeding, or indigestion, can be ascer- 
tained to exist, calomel is to be preferred to the emetic ; half of or one 
grain of calomel is to be given to the child every hour, until a few 
evacuations have been produced. When constipation is the presum- 
able cause of the eclampsia, a clyster may be administered, even 
during the convulsions. I have never been compelled to resort to 
croton-oil in this affection. 

Of all the antispasmodics, oxide of zinc, in one or two grains 
pro die, is the most useful, and best adapted for a prolonged use. 
It is rather difiicult to form an opinion as to the benefit derived 
from such prophylactics, for the reason that in most eases but one 
eclamptic fit occurs. Narcotics are not admissible in this disease, 
because they do not act quickly enough, when administered dur- 
ing the fit, to arrest it, and afterward are apt to induce cerebral 
congestion. 

An after-treatment, by the use of tonics, iron, quinine, and ale, 
may be indicated, chiefly after eclampsice consequent upon gastric 
and dental irritation. 



DISEASES OF THE NERVOUS SYSTEM. 323 

(2.) Paralysis. — Since central paralysis, produced by diseases of 
the brain and spinal cord, has already been mentioned in connection 
with those affections, we still have to speak of what has been called 
essential paralysis of one or more extremities, coexisting with per- 
fect integrity of the nervous centres, and also of the peripheral 
paralysis of the facial nerve. 

As regards facial paralysis, it is sometimes observed immedi- 
ately after birth, but, on account of the immobility of the features, 
it is much more difficult to recognize in the new-born child than 
in the adult. The lesion does not become noticeable till the child 
begins to cry ; the angle of the mouth on the sound side is then 
seen to be drawn outward, and the whole healthy moiety of the face 
is generally thrown into folds, while the paralyzed half remains as 
immovable as before. When the cause of the paralysis is central, 
the uvula will also be seen to stand obliquely ; in most instances, 
however, no alteration whatever can be observed on the palate 
and uvula, as the cause of the paralysis usually lies in the course 
of the facial nerve. The most frequent cause of the paralysis of 
the new-born child is to be found in the use of the forceps. In 
addition to this, it may also be due to a congenital smallness or 
distortion of the j^etrous portion of the temporal bone, which occa- 
sionally occurs. Later in life, caries of this bone, glandular indura- 
tions, and contracting cicatrices in the vicinity of the facial nerve, 
are the most common causes. 

The treatment of facial paralysis depends upon its cause, and is 
effectual only when that is capable of removal. Contracted cicatrices, 
most frequently the result of scrofulous ulcers, and glandular tumors, 
may be removed by an operation ; on the other hand, paralysis, the 
effects of caries of the petrous portion of the temporal bone, as a rule, 
is irremediable. 

Essential paralysis of single extremities, very briefly alluded to 
in the older text-books, is a much more frequent and interesting 
affection, and has lately been more accurately described by Heine, 
Kennedy, and Milliet. 

By essential paralysis is understood a partial or complete loss of 
power of motion, and of sensibility in one or more extremities, with- 
out any discoverable evidence of its depending upon lesions of the 
nervous centres. That the central organs have experienced none, at 
least no material alteration, may be readily concluded from the facts 
that the paralysis sometimes disappears very quickly, after two or 
three days, and from the reports on autopsies of children with essen- 
tial paralysis who had succumbed to other acute affections. liilliet 
and JBarthez have had two opportunities to dissect such bodies, and 
Fliess has had one. The former found no alteration whatever in the 



321 DISEASES OF CHILDREN. 

brain and spinal cord ; the latter, in a case of paralysis of one arm, 
found a simple congestion of the meninges of the cord on a level 
with the brachial plexus. Post-mortem examinations of essential 
l^aralysis are always very rare occurrences, because this disease per 
se is not apt to terminate fatally. 

Symptoms. — Paralysis, usually, in most instances, begins in this 
manner : The child, during dentition, but otherwise in good health, 
falls asleep at the usual time in the evening, is somewhat restless 
during the night, and, on the following morning, awakes with one arm 
or leg, seldom both legs, paralyzed. The palsy is complete on the 
very first day of its occurrence. In other instances, difficulties of 
dentition, with convulsions, or even eclamptic fits, precede it for sev- 
eral days. The palsies which follow these phenomena are mostly 
hemiplegic or paraplegic, and are of longer duration than those 
which originate in a simple manner. In exceptional cases, essential 
paralysis of the lower extremities follows corea, typhus fever, and the 
acute exanthemata. In these latter cases it develops itself most 
markedly during convalescence. It is very questionable whether it 
is really always primarily peripheral, and originates without any 
morbid alterations of the meninges. That paralysis which affects one 
extremity, most frequently the upper, and which comes on suddenly 
during tlie night, and without the least disturbance of the general 
system, presents the simplest form of essential paralysis under dis- 
cussion, and to it we will now call attention. 

Although the whole group of symptoms must be regarded as 
complete from the very beginning of the disease, still, two stages 
may be distinguished in its course : (1), the stadium of simple paral- 
ysis ; and (2), that of atrophy. 

The second stage, when the disease runs an acute course, and 
soon passes into recovery, does not take place at all ; it only occurs 
in cases that have lasted for some months. In the first stage, no 
alteration can be discovered in the length, circumference, or tempera- 
ture of the affected limb, but, when the malady is longer in duration, 
the limb begins to waste, the muscles become flabby and thin, the adi- 
pose tissues also decrease, and, lastly, even the longitudinal growth 
of the bone is more or less arrested. 

As regards the symptoms of the individual palsies, those of the 
arm manifest themselves in the following manner : The arm hangs 
powerless by the side. It is a remarkable fact that paralysis of the 
muscles of the arm occasionally occurs, without involving the mus- 
cles of the hand and fingers of the same limb. The reverse of this 
condition has never, to my knowledge, been observed. In this case 
the patients are still able to grasp with the hand, but are unable to lift 



DISEASES OF THE NERVOUS SYSTEM. 325 

the grasped object. For example, they can grasp the spoon, but can- 
not carry it to the mouth. Older children try hard to use the affected 
limb, and assist it with the sound one. The only alteration of form 
that is noticeable from the very commencement is, a flattening of the 
outer contour of the shoulder, caused by a paralysis of the deltoid 
muscle, and the weight of the dependent arm itself. 

Essential paralysis of a lower extremity seldom implicates all the 
muscles of the limb ; it often affects only those of the leg, and not 
always all of these. The foot is inclined either inward or outward, 
according to the muscles affected. The disease is very easily recog- 
nized. In children not yet able to stand, the palsied limb lies qui- 
'etly during their crying and struggling, while the other is drawn up 
against the body, and, when seated upon a chair, the paralyzed limb 
dangles about lifelessly. In children who have walked, the signs are 
still more mai'ked. They make no further attempts to walk, or, if it 
be a partial paralysis — that is, of only certain of the muscles — will 
drag the leg after them, or hop on one foot. 

When both lower extremities are affected, the child will lie mo- 
tionless in bed. It, however, soon learns to sit, aided, perhaps, by 
returning functional ability of the limbs, which progresses from 
above downward, so that it is first able to move the thigh, next the 
leg, and finally the foot. 

The peculiarity of this peripheral paralysis is, that neither the 
bladder nor the rectum ever becomes affected by it. 

Its course and duration are variable. In most cases, the palsy 
disappears completely after a few weeks or months, without leaving 
any effects behind, but, when it lasts longer than six to eight 
weeks, without any improvement having taken place, the signs of 
commencing atrophy, so far as concerns the alterations of form, 
will ensue. A marked decrease in the temperature of the skin soon 
becomes superadded, followed by complete anesthesia, and fre- 
quently, also, by slight oedema of the dorsum of the feet, the chief 
cause of which is, undoubtedly, the feeble circulation of the affected 
limb. 

The atrophy never proceeds so far as that it is not still possible, 
by faradization, to produce contractions of the single muscles. The 
sensibility in the paralyzed limb is continued for a much longer 
time, but whether it is as perfect as in the sound limb is not easy 
to decide, for the children are mostly still too young to be able to 
make very fine discriminations. During the first few days after 
the invasion of the palsy, hyperoesthesia and decided painfulness 
are sometimes observed, seemingly due to inflammation of the neu- 
rolemmata ; still, they may also be suspected to be caused by pre- 
22 



326 DISEASES OF CHILDREN". 

ceding contusion, or they may be feigned. After several days, these 
pains disappear. 

The longer the palsy exists, the greater the alterations of form 
become. The shoulder-joint becomes enfeebled to such a degree 
that a dislocation of the upper arm may take place. A depression 
appears beneath the acromion process, and the deltoid muscles 
become completely flattened. In partial paralysis of the lower 
extremities, contractions in the direction of the sound muscles oc- 
cur, producing club-feet and genu valgum on the lower extremities, 
and scoliosis of the spinal column, in consequence of obliquity of 
the pelvis. 

In regard to the duration of this disease, liilliet and Barthez 
have furnished us with more accurate statements. In one case, a 
well-marked essential paralysis disappeared in twelve hours ; in 
many others, in from six to eight days. Complete recovery has 
been seen to take place after a duration of eleven months. Even 
when the affected extremity exhibits imperfect development, and 
is able to perfoi-m but few and feeble movements, it is still possible, 
even after the lapse of years, by proper gymnastics, and by the use 
of electricity, to improve its condition, and, perhaps, to cure the 
disability. 

It is remarkable that the sensibility/ of the skin of the palsied 
limbs is never affected, and the reflex irritability is unaltered. The 
affected muscles, as regards electricity, are at first entirely unal- 
tered, but when they commence to atrophy the electro-muscular 
contractility diminishes more and more under the induction-current. 
After a few weeks it is generally entirely gone, while the galvano- 
contractility may still be roused, though very slowly. At the end 
of a year both kinds of contractility are gone forever. The trophic 
disturbances visibly increase, the adipose tissue disappears from the 
palsied limbs, and the temperature diminishes. Owing to the atro- 
phy of the adipose tissue and of the muscles, combined with the 
traction which the limbs through their own weight exercise upon 
the capsules of the joints, the latter become more and more promi- 
nent, and finally present the picture of atonic luxation. Even the 
bones are retarded in their longitudinal growth ; still, this shortening 
never amounts to much, so that in the adult the difference between 
the palsied and the sound limb scarcely amounts to from one to 
two centimetres. 

The deformities which follow essential paralysis are manifold. 
The most common on the lower extremities are pes varus or varo- 
equinus, less frequently valgus and calcaneo-valgus ; on the upper, 
permanent contractions of the hand and fingers ; on the body, cur- 



DISEASES OF THE NERVOUS SYSTEM. 327 

vatures of the vertebrae, projections of the scapulge and caput ob- 
stipum. 

Etiology. — The views of Rilliet and Barthez, who first used the 
term essential paralysis, are opposed by Heine, who substitutes for 
that term the name of spinal paralysis of infancy. Heine bases his 
views upon the presence of a morbid lesion, of an inflammatory- 
nature, in the spinal marrow and its membranes, which, however, 
has not been proved. Yogt and Duchenne accept his views. Now, 
although it cannot be denied that the disease often begins with 
general symptoms, such as fever and convulsions ; also its sudden 
invasion, its early extent, and subsequent limitation to a few groups 
of muscles, render it probable that it is due to a central lesion, still 
the designation "spinal" is not justifiable, for the convulsions and 
coma which precede the disease may as well point to a lesion of the 
brain as to that of the spinal cord. Often enough only a partial 
paresis of a few muscles has been observed for a long time to pre- 
cede a disease of central origin in the brain, such as neoplasms and 
sclerosis of that organ. 

Essential paralysis is a disease of early childhood, and is most 
decidedly connected with the eruption of the teeth. Children under 
half a year are but seldom affected with it ; most frequently it 
comes on at the eruption of the molar teeth, and becomes extremely 
rare after the completion of dentition. More boys than girls, ac- 
cording to my experience, are afflicted with it. This, however, may 
also be accidental, for, in the more recent text-books, this dispro- 
portion is not alluded to. 

The state of the constitution seems to possess no influence in 
this disease, for most of the children attacked by paralysis have 
enjoyed good health, and have flourished well up to the time of 
the attack. While scrofulous children are sometimes its victims, 
there is, nevertheless, no conclusive evidence that the very common 
scrofulous cachexia furnishes any special predisposition to the dis- 
ease. The only tolerably constant occurrence in it is congestion of 
the brain, and disposition to constipation during dentition. In some 
of the more recent works it is stated, with especial emphasis, that 
exposure to cold is the most frequent exciting cause ; but a single 
case, however, is cited, in support of this statement, namely, that of 
a child which sat upon a cold stone, and thereupon contracted a 
paralysis of one of the lower extremities. The many hundred other 
children, especially those belonging to the lower classes, who ha- 
bitually sit upon cold stones, and yet escape the disease, furnish 
evidence which weakens this theory as to the exciting cause of the 
disease. 



328 DISEASES 0? CHILDREN. 

Prognosis. — During the first few days it is impossible to make a 
positive diagnosis, for extensive paralysis attended with grave ini- 
tial symptoms may get well rapidly, and a limited paresis may last 
through life. Not till one or two weeks have elapsed is it possible 
to say in a given case whether the palsy is of a benign and transient 
character or of the pernicious and permanent form. If the muscles 
no longer respond to the galvanic or faradic current, and the nutri- 
tion begins to fail, the paralysis may with certainty be pronounced 
incurable. 

As regards the infirmity of the individual patients, the progno- 
sis depends greatly upon the site of the paralysis. The deformity 
of the limbs is often caused more by the palsy of a single group of 
muscles and the consequent loss of antagonism of other groups than 
by the paresis of an entire limb. On the arm, palsy of the muscles 
of the shoulder may still permit a limited use of the hand, while 
paralysis of the flexors of the forearm and muscles of the thumb 
render the whole extremity useless. 

Therapeutics. — The antiphlogistic treatment, local abstraction of 
blood, calomel, etc., has, as in almost all diseases, also been em- 
ployed in this paralysis, but without better results than those ob- 
tained from the expectant treatment. The same may be said of 
purgatives, and, in fact, of all the other remedies recommended in 
its treatment. Many of these have been enthusiastically praised, 
because most essential paralyses disappear after one or several weeks, 
whatever agents have been employed. But, as to a specific effect 
of the remedies recommended, it is futile to speak, for there are 
many cases of essential paralysis, as to the diagnosis of which there 
is no doubt whatever, and yet resist all methods of treatment, even 
that with electricity. 

The most rational and the sionplest treatment for the first few 
weeks of the paralysis seems to be the daily employment of the cold 
douche, afterward wrapping up of the limb warmly, passive motion, 
and spirituous frictions. Most essential paralyses are easily cured 
by these means. If, after four weeks, no improvement is effected, 
then it is time to obviate, by induced electricity, applied daily for 
ten minutes, the consecutive atrophy of the muscles. 

If, after several weeks more, no improvement is realized, the in- 
ternal use of sulphate of strychnia, -^ to|- gr. pro die, may be resorted 
to. This preparation is much preferable to nux vomica, on account of 
the variable quantity of strychnine the latter contains. The utmost 
caution should be employed in the use of this remedy ; the relatives 
should be informed of its toxic action, and precautionary measures 
should be adopted in case sudden violent tetanic attacks happen to 



DISEASES OF THE NERVOUS SYSTEM. 329 

come on. The best means for this purpose is to dash some cold water 
on the body, and to administer strong coffee. 

Deformed extremities must be restored to their normal shape by 
orthopaedic treatment, and, for the incurable paralysis, mechanical 
orthopgedia, with its numerous ingenious apparatus, may likewise be 
advantageously resorted to. 

(3.) Chorea Minor. Thk Little or Ejstglish St. Vitus's Dance, 
Muscular Jactitation. Involuntary Movements of the Muscles. 
Ballismus, Scelottrbe. — The best description of the little St. Vitus's 
dance is given by Sasse, in his Diseases of the Nervous System, in 
Virchoto's Pathology and Therapeutics, and which also forms the 
basis of the following characteristic description. 

By chorea minor we understand a constant involuntary move- 
ment of almost all the voluntary muscles, which increases in severity 
when the movements are being directed by the will, and ceases only 
with the total abolition of consciousness ; for example, in sleep. This 
definition sufficiently distinguishes St. Vitus's dance from the other con- 
ditions which were formerly spoken of in connection with it, such as 
the great St. Vitus's dance, the dancing mania, the imitatory popular 
diseases, and the tarantula disease. 

Symptoms. — The constant involuntary jactitations are seen either 
in all the voluntary muscles of the body or in some portions only. 
They may be seen in the upper moiety of the body, or confined to one 
side ; in one arm, and the corresponding leg, giving rise to the 
dance-Hke movements in those limbs. In very rare instances one arm 
and the opposite leg are affected by this muscular restlessness. Nor 
are all the extremities always imphcated in a uniform manner, for, 
while one arm is not at rest for a single moment, twitching inces- 
santly, the other may be at rest for several minutes, and, indeed, 
only be affected by slight, barely-perceptible muscular tremors. The 
same inequaUty of the affection is also observed in the lower extremi- 
ties. The muscles of the face may possibly be wholly spared, while 
those of the lower extremities are in an incessant state of jactitation. 

Now, as regards the single twitchings, those on the upper ex- 
tremities, as a rule, are the most noticeable. The most peculiar distor- 
tions and tremors are observed in the arms ; the shoulders are drawn 
high upward, as if the patient were trying to scratch himself; the fin- 
gers are sometimes closed, and then again extended, or they are in- 
cessantly employed in pulling at the garments. The feet are not at 
rest for a single instant, and an incessant stamping is produced by the 
different involuntary contractions. When the patient lies down, the 
toes spread out, and contractions also take place at the knee-joint. 
The gait becomes unsteady and uncertain, and, in extreme cases of the 



330 DISEASES OF CHILDREN. 

affection, walking becomes altogether impossible. When one limb is 
more severely affected than the other, it produces limping. The 
most singular movements take place about the head. It is twisted, 
shaken, sometimes spasmodically drawn to one side, and then again 
to the other. The contractions of the facial muscles produce the most 
wonderful contortions which may even degenerate into the severest 
caricature-like grimaces. The eyes glare, or temporary strabismus 
comes on, and the eyelids usually blink incessantly. 

The muscles of mastication and deglutition also become affected 
by the restlessness, and during mastication the patients bite the 
tongue or mucous membrane of the cheek. Even gnashing of the 
teeth, when the mouth is empty, occurs. Deglutition is not always 
performed according to the will, nor are the movements of the tongue. 
Hence these children stutter, stop in a middle of a sentence, and often 
bite their tongue in the attempt to speak. The body is turned about 
and twisted in every direction. The respiratory muscles, however, do 
not noticeably participate in the jactitation, at least the inspirations 
are not executed irregularly. 

The immediate effect of this condition is of course a constant in- 
terference with the voluntary movements, which react and cause a 
visible aggravation of the convulsive affection. The patients are un- 
able to eat properly, are attacked by twitchings while in the act of 
carrying the food to the mouth, they bespatter themself with fluids, 
and prick themselves in the face, if imprudently a fork has been al- 
lowed them. While in the act of -writing, they will suddenly make 
long hooks, and crooks in the letters, or thrust the pen so violently 
upward as to pierce through several pages of the copy-book. When 
they attempt to undress themselves, such violent tremors result, in con- 
sequence of the greater voluntary movements necessary for that pur- 
pose, that the clothes are torn. Wlien they are commanded to stand 
quietly, the very effort to comply only renders the stamping still 
greater. If ordered to protrude the tongue, that organ will be rolled 
out of the mouth with the most peculiar shiftings and twistings, and 
can in no case be kept quietly protruded for any length of time. 

When an attempt is made to hold the affected part firmly, the 
restlessness becomes still more aggravated than when a voluntary 
movement is undertaken. A permanent aggravation of the whole 
affection may even be produced thereby. 

The sensibility of the skin is not diminished in chorea, and the 
ordinary reflex movements may be induced by the various cutaneous 
stimuli, such as pricking, burning, etc. Also sneezing and gaping 
are executed without any hinderance, nor does the disease seem to 
exercise the least influence upon the evacuation of the bowels or 



DISEASES OF THE NERVOUS SYSTEM, 331 

bladder. It is worthy of remark, and a curious fact, that these chil- 
dren, even in the severest cases, where they are the whole day 
through in a constant state of agitation, never complain of fatigue, 
the contractions being as severe in the evening ; often, indeed, they 
even become stronger. No constant signs of any disease in the 
nervous centres can be detected in this aifection. Nor has the symp- 
tom advanced by Siehel, of pressure along the vertebral column almost 
always producing pain, been confirmed by other observers. 

The disposition of the mind in choreic patients often undergoes a 
change. They are much inclined to weep, and become choleric ; pre- 
viously well-disposed and kind children become petulant and malicious. 
If the disease is protracted for a long time, the memory will also become 
somewhat impaired. Numerous and noticeable as the sj^mptoms are 
when the child is awake, in sleep they almost disappear. In the 
evening when the patients become tired and lie down, the jactitations 
gradually subside, and cease completely as soon as consciousness is 
gone. The sleep is usually less tranquil than in healthy children, and 
even some slight choreic movements are made during dreams, but, 
with the awaking, all the symptoms come on again with their former 
severity. 

Chorea is not attended by fever, and runs its course without any 
visible disturbances of the general system ; on the contrary, it has even 
been observed that the muscular twitchings became markedly feebler 
during the course of an intercurrent acute affection, for instance, an 
acute exanthema, and, in that case, are quickly followed by a per- 
manent improvement, and a complete recovery. The pulse, in simple 
chorea, is neither irregular nor accelerated ; the contradictory state- 
ments of some authors are probably due to the difficulty of seciu'ing 
the radial artery, owing to the constant jerking of the tendons. But, 
if the heart is carefully auscultated, it will be conclusively seen that 
the rhythm and frequency of the cardiac contractions are always 
normal. 

When the disease lasts for some time, the nutrition wiU now and 
then suffer materially, the children become pale and lean, and, in older 
girls particularly, anasmic cardiac murmurs and chlorotic symptoms 
generally manifest themselves. 

Its course is always chronic, and a tolerably well-developed chorea 
is scarcely ever ciu-ed in less than two or three months, others last 
half, and even a whole year ; indeed, Romberg relates the case of an 
old woman seventy-six years of age, who suffered from chorea seventy 
years, was still living, and would undoubtedly take it with her to 
her grave. 

Chorea has also been divided into stages, such as (1), the stadium 



332 DISEASES OF CHILDREN. 

of premonition; (2), of aggravation; (3), of the climax; and (4), of 
subsidence. But divisions into stages, in diseases where the transi- 
tions are so gradual, and are not ushered in by any marked symptoms, 
have but little value. The invasion of the disease is gradual in all 
cases. The subjects noticeably become awkward, drop every thing, 
break almost every thing that is given them, often stumble, and be- 
come anxious and intimidated in consequence of the injuries which 
they suffer as the result. Generally, the first involuntary movements 
take place after some mental excitement, such as fright, fear, anger, 
etc. At fii-st they are seen in some small groups of muscles, but sub- 
sequently, and more or less rapidly, become general, so that in two 
or three weeks the disease has attained its climax. From that time 
the symptoms remain stationary for at least four to six weeks, with- 
out undergoing any exacerbation or amelioration. Finally, an almost 
imperceptible improvement ensues. Relapses, however, are of frequent 
occurrence. See observed them thirty-seven times in one hundred 
and fifty-eight cases. In the end, however, a complete recovery gen- 
erally takes place. An exceptional case may sometimes occur, in 
which a twitching of individual groups of muscles, especially of 
the face, remains for years, or through life. IVicJce and Leudet also 
describe some fatal attacks. The disease, in those cases, rapidly as- 
sumed a form of the utmost gravitj?-, coma came on, attended by the 
involuntary passage of the stools and urine, soon followed by collapse, 
irregular respirations, small pulse, and death. 

Etiology. — Chorea is almost exclusively a disease of childhood, 
and, when adults suffer from it, it will be found that they acquired it 
during their youth. Most frequently it attacks children between the 
sixth and sixteenth years, owing to which, its origin . has sometimes 
been sought for in the second dentition, and then again in the pros- 
pective puberty. Although these processes may also furnish a dispo- 
sition to cliorea, still their connection with it is not a very intimate 
one, for, it very frequently disappears without a molar tooth having 
been cut through, or menstruation having made its appearance. 

Chorea is one of the few diseases which attack the sexes in un- 
equal numbers. According to a compilation by Duffosse^ seventy- 
nine out of two hundred and fifty patients were males, and one hun- 
dred and sixty-one females, and See maintains that the ratio of cases 
of the disease among boys, as compared with girls, is as one-third 
to two-thirds. Here, in Munich, this disproportion seems to be still 
greater, for, among eleven chorea patients which I noted in my diarj^ 
I find only one boy affected. 

No special inheritance exists here, and it happens only exception- 
ally that the child, of a mother affected during her youth with chorea. 



DISEASES OF THE NERVOUS SYSTEM. 333 

is attacked by it. On the other hand, however, the fact is not to be 
ignored, that most of the mothers of such children have an irritable 
nervous disposition, and suffer from the most varying forms of hys- 
teria. I*receding febrile diseases likewise predispose one to chorea. 

No distinct influence of the season of the year can be perceived in 
this country, while chorea very seldom occurs in the tropics ; in the 
northern latitudes, on the contrary, it is said to be more frequent. 
Whether it may also be epidemic, as is claimed by some of the 
investigators of medical history, is still not satisfactorily established. 
Those so-called epidemics are probably referable to simple imitation. 
That chorea may originate in girls' boarding-schools, as the result of 
mimicry, is vouched for by many reliable observers, and instances of 
that nature have recently occurred in a Tyrolean village, and in a 
pensionnat at Eisenach. 

We find an analogy for this circumstance in the origin of hysteric 
spasms, by merely seeing a person suffering from such convulsions, as 
is often observed in the female sections of large hospitals. 

Fright, in particular, is often accused of being a psychical cause. 
It may, no doubt, hasten the outbreak of chorea in a child commen- 
cing to suffer from it ; but if fright is really capable of producing it 
in one who is healthy in all other respects, then we ought to have 
many more choreic patients, for there are many timid children who, 
by the slightest cause, are greatly frightened. 

See lays great stress upon the connection between chorea and 
rheumatism, discovered by himself. This connection, however, seems 
to be a very loose one indeed ; for, although it must be acknowledged 
that chorea may succeed to acute rheumatism, still the frequency of 
the occurrence has been very much over-estimated. In cities where 
much rheumatic sickness occurs, chorea ought to abound, and vice 
versa, but it is not so. In Geneva, for example, according to HiUiet^s 
statement, there is a great deal of rheumatism and hardly any St. 
Vitus's dance. Moreover, if there were any actual connection be- 
tween them, then more girls than boys ought to suffer from rheuma- 
tism ; for it is well known that the former are predominantly subject 
to chorea. Just the reverse happens to be the case in rheumatism, 
which notoriously attacks more boys than girls. 

Pathological anatomy furnishes totally negative results in this dis- 
ease, which may, in part, be due to the rarity of fatal attacks. jFro- 
riep found the odontoid process of the axis thickened in two cases, 
and describes it as a simple hypertrophy of its osseous substance. 
They are, on the whole, too solitary instances for any definite conclu- 
sions to be drawn from them. In fact, the true cause of chorea has 
not yet been fathomed, notwithstanding the numerous theories ad- 



334 DISEASES OF CHILDREN. 

vauced by Slehel, sen. and jun. ; also the connection with worms, upon 
which great stress was fonnerly laid, in reality does not exist, for 
otherwise chorea would probably be more frequent in worm regions, 
and be cured by anthelmintics, which, however, is not the case. 

Diagnosis and Prognosis. — The disease is usually so easily recog- 
nized, that even every lajnnan who has once seen it knows it again at 
a glance. It distinguishes itself by the uninterrupted and protracted 
duration of the symptoms, which last for many weeks, from all other 
convulsions that have been embraced under the not very appropriate 
denomination of chorea-like affections. To the latter belong stutter- 
ing, blinking, contractions of the angles of the mouth, the so-called 
weaver's and writer's cramp, over which, collectively, the will has 
some, although very little, influence. Besides, these affections occm 
only paroxysmally, or at the most diurnally, and are by no means as 
continuous as chorea. The disease described by Dubini under the 
inappropriate name of chorea electrlca may be easily distinguished 
from chorea by the fact that, in this condition, according to Sasse, 
there are headache and pains in the back, followed by electric twitch- 
ings of the lower extremities, at first confined to one side, but soon 
extending over the whole body ; general convulsions, Avith perspirations 
and fever, now supervene, and the patient dies paralytic in a few 
weeks. 

The prognosis in the great majority of cases may be set down as 
favorable, and that in three, or at the most six months, most of the 
children under a treatment that is at all rational will recover com- 
pletely. That kind of chorea which, according to some authors, runs 
into epilepsy and imbecility, depends, in fact, upon organic disease of 
the nervous centres, and consequently ought not to be classed with 
pure St. Yitus's dance. 

Relapses are not of rare occurrence ; I have had two children 
placed under my care, who had completely recovered, were entirely 
free from muscular twitchings for several months, and were again at- 
tacked by a tedious chorea. A most decided disjaosition to neuralgia 
of all kinds remained behind in these children. It is a remarkable 
fact that the cure in boys, according to statistical compilations, takes 
place much slower than in girls ; in the former the treatment lasting 
seventy-four to eighty-one days, in the latter only thirty-three to 
thirty-seven days. The latter averages seems to me to have been 
put rather too low. 

Therapeutics. — The main reason why a treatment directed to the 
cause can hardly ever be practised is, because the true cause of the 
disease has not yet been fathomed, as has abeady been shown. In 
this respect we should pay attention to the condition of the patient's 



DISEASES OF THE NERVOUS SYSTEM. 335 

residence, to the evacuation of worms, onanism, menstruation, and 
rheumatic complications. 

Its treatment, with the countless number of remedies that have 
been recommended, can only, then, be properly appreciated when we 
bear in mind the spontaneous recovery from chorea. Indeed, a cure is 
often accomplished in a few weeks, or, at the most, months, with 
almost any remedy, however absurd, but not intensely toxic. Tliis su- 
perabundance of remedies is only found in two classes of diseases and 
which are diametrically opposite in their terminations, namely, in those 
which recover spontaneously, and in those that are almost certainly 
incurable. Epilepsy may be taken as a prototype of the latter. 

Abstractions of blood were considered appropriate when the dis- 
ease occurred with vascular excitement in robust subjects, and Syden- 
ham was brought forward as an authority for this practice. It seems 
to me, however, that every antiphlogistic measure is totally useless, 
if not actually injurious, for the vascular excitement alluded to is not 
in the least critical ; and an anaemic condition, when the disease lasts 
for a long time, supervenes spontaneously, which condition is only 
accelerated by the previous abstractions of blood. Counter-irritants 
applied to the nape and spinal column, among which ointments of 
tartar emetic and sublimat., vesicants, and croton-oil, hold a high 
place, are useless tortures, and leave upon the poor patients perma- 
nently disfiguring cicatrices, which may, in future years, mar their 
attractions and mortify their pride. 

Derivatives applied to the intestinal canal are less objectionable, 
and the most appropriate remedies are the neutral salts, castor-oil, 
rhubarb, senna, and aloes, and, when the presence of intestinal worms 
is suspected, they may advantageously be combined with vermifuge 
remedies. Calomel and tartar emetic, on account of their subsequent 
constitutional effects, should be avoided, whether in large or small 
doses, for it is certain that they exercise no marked influence upon 
chorea. 

When vascular turgescence is absent from the very beginning, em- 
pirical remedies may be resorted to at once. Among these, iron is, to 
say the least, the most rational, especially when the child is anasmic, 
and suffers from incipient chlorosis. The preparations of iron, and 
mineral waters containing iron, are recommended by the most experi- 
enced phj'^sicians as useful, and may be given for many weeks without 
detriment, even after the muscular jactitations have subsided. Serious 
constipation, resulting from this joractice, should be relieved by the 
above-named aperients. So far as the effect of the remedy upon the 
nervous system is concerned, it is almost immaterial which prepara- 
tion is selected ; this may be decided on the grounds of its digesti- 



336 DISEASES OF CHILDREN. 

bility, and the ease with which it is taken. Children, especially young 
ones, are not good at swallowing pills ; although they will swallow 
large numbers of cherry-pits with the greatest readiness. They bite 
pills, and retain the pieces in the mouth till they become soft, and 
their disgusting taste renders t]]e object sought, viz., the introducing 
of remedies in a tasteless form into the stomach, unattainable. The ad- 
ministration of powders is, in the long run, inconvenient, as they have 
often to be frequently repeated at the apothecary's, on account of their 
deliquescent character. I, therefore, prefer the tincture of iron, and 
almost always use the ext. ferri pomati, which seems to be most easily 
assimilated. Homherg recommends ferrum cyanatum ; others the sul- 
phate and carbonate of iron. According to my experience, large doses 
of iron do not act more favorably upon the course of chorea than small 
ones ; besides, they are more apt to cause disturbances of digestion 
and constij^ation, and, for this reason, I do not consider it advisable to 
go beyond twenty to thirty drops pro die. During convalescence, 
quinine, cinchona, and other tonics, may also be given ^vith advantage. 

There are, in addition, a number of empirical remedies, which are 
more highly praised than brilliantly curative. The first to be men- 
tioned here are the metalhc remedies, zinc, copper, and arsenic ; and, 
of all the zinc preparations, the oxide is mostly preferred, given up to 
sixteen grains, three times daily ; next, sulphate of zinc, in one to 
eight grain doses ; cyanide of zinc, daily, up to three grains ; and, 
lastly, ferrocyanide of zinc. Escolar praises valerianate of zinc, in two 
to twelve grains pro die. 

Sulphate and ammoniate of copper have been justly abandoned, on 
account of their nauseating action. The same should be done with 
Fowler's solution, an article which Henoch has recently so strongly 
recommended. 

It seemed quite pertinent to try narcotics in chorea, and various 
experiments have been made with them. Opium, belladonna, haschish, 
hyoscyamus, hydrocyanic acid, aconitine, and atropine, have been dis- 
carded long ago ; so, too, strychnine, first suggested by Trousseau — • 
who has been most unfortunate with his therapeutic discoveries — ^has 
been abandoned by all rational physicians. 

In very severe chorea, where the children are unable to obtain any 
rest at night, temporary palliation may be derived from chloroform. 
But, when too often repeated, these inhalations afi'ect the head un- 
pleasantly, and disturb the digestion. 

Animal and vegetable nervines have been quite as generally em- 
ploj^ed as narcotics ; valerian, assafoetida, camphor, moschus, castoreum, 
colchicum, etc. Cold baths and douches are of decided benefit, and, 
as they are mostly disagreeable to the children, exert a good influence 



DISEASES OF THE NERYOUS SYSTEM. 337 

by inducing them to use every possible voluntary effort to avoid the 
necessity of their application. Under this influence, they may resist 
the involuntary movements to some extent. Dupuytren is an enthu- 
siastic advocate of cold baths and douches, and holds that, with their 
persistent use, every case of chorea is curable, in which declaration, 
however, he may possibly go too far. 

Of late, warm baths, and warm sulphur-baths in particular, have 
come into use, as many girls are unable to bear cold baths. For this 
purpose, four ounces of sulphate of lime are added to every bath, in 
which the children are allowed to sit for an hour every day. JRufz 
is of the opinion that, by this measure, the disease is shortened to 
twenty-four days ; JS^ohler, however, observes, in this connection, that 
there are also cases where the disease becomes aggravated by it, and 
prohibits the further use of the sulphur-bath. 

As regards the psychical treatment of chorea, more harm than good 
is often done by harshness and severity ; but by this we do not intend 
to say that the stimulation of the volition should be entirely aban- 
doned. By kindness and promises of presents, the children should be 
urged to keep quiet until ten or twenty are counted ; they should be in- 
duced to make simple and easy efibrts to control the movements of the 
hands and feet, and, when successful, should be praised, etc. 

Formerly, it was considered injurious to hold children firmly, 
or to tie them or bandage them in splints ; lately, however, cases have 
been reported where the apphcation of the splints — at first at night 
only, where the children, on account of the severity of the chorea, 
were unable to obtain any rest ; subsequently, also, by day and night, 
continued for many days — produced a remarkable improvement, and 
ultimately led to a cure [Monahan, of Dublin). It certainly will only 
be necessary, in this treatment, to fix gently the extremities, by prop- 
erly bent and padded splints, while it will seldom be possible to re- 
strain the motions of the body. This method, at any rate, deserves a 
further trial. 

The little voluntary exercises, recommended above, have been more 
systematically developed by the Swedish-movement cure, by first prac- 
tising passive, then the so-called duplicate, and, finally, active compli- 
cated movements. 

The dietetic treatment is of little importance. The irregularly and 
badly-fed children of the poor recover as rapidly as those of the wealthy 
class, where every morsel of bread and meat is first subjected to the 
physician's examination before it is given to the patient. A healthy, 
dry residence, and the enjoyment of fresh air, accelerate the cure ; 
mental exertions retard it, and those addicted to onanism it is often 
entirely impossible to cure. 



338 DISEASES or childrex. 

If we make a resume of the entire treatment, we shall find it to con- 
sist essentially of cold baths and douches, of the administration of 
iron, and prudent psychical strengthening of the will. In the severest 
form, chloroform is to be preferred to narcotics, and a trial with splints 
would also be rational. 

(4.) Chorea Major (the Great St. Vitus's Dance) — Chorea Ger- 
MANORUM. — A very rare affection, in which term spasmodic diseases 
of various kinds are included. Chorea major attacks girls almost 
exclusively, and only those who are approaching puberty. The 
essential character of this disease consists in this, viz. : the children 
are attacked by paroxysms of regulated movements, apparently exe- 
cuted with consciousness and proper will, in which a peculiar potency 
of the mental abilities manifests itself. The transition into somnam- 
bulism, animal magnetism, miraculous mania, etc., is very apt to hap- 
pen, and it requires the utmost professional sagacity to strike the exact 
boundaries between imposition, or deception, and an actual pathologi- 
cal state. 

Sjrmptoms. — The phenomena vary so much in individual patients 
that it is difficult to sketch a picture of s^Tiiptoms apphcable to all 
cases. The outbreak of the paroxysm is almost always preceded by 
psychical and corporeal premonitions. To the first belong sadness, 
great moodiness, depression of spirits, fear of phantoms, active 
dreams, and restless sleep ; to the latter, palpitation of the heart, 
cardialgia, disturbances of digestion, anorexia, headache, and pain in 
the back, may be added. 

Finally, actual paroxysms develop themselves. The patients 
begin to make apparently voluntary, sometimes simple, sometimes 
again complicated movements, which they execute with vmnatural 
strength, steadiness, rapidity, and perseverance. The patients are 
seen to perform the movements of swimming, climbing, jumping, 
dancing, crawling, and attempting the most wonderful contortions of 
the body. 

In others, again, it approximates more to pure psychical alienation 
or exaltation ; they begin to declaim, compose, preach, and sing with 
great volubility, or to talk nonsense with lofty pathos, or to imitate 
the cries of beasts. 

The influence of the will is not always completely abolished ; some 
cannot be roused from the paroxysm by any means, not even by in- 
flicting any amount of pain, while others, again, are recalled to con- 
sciousness by simply dashing water in the face. 

This condition most resembles the incomplete narcotism from 
chloroform, in which the patients are in an unusual state of excitement. 
Sometimes these paroxysms last only a few minutes ; then, again, 



DISEASES OF THE NERVOUS SYSTEM. 339 

Beveral hours ; and end eittier by the patients becoming more calm, 
or then waking up as from a dream, and looking about in surprise, or 
by relapsing into a profound sleep, often lasting several hours. The 
recollection which the patient has of what transpires during these 
paroxysms is variable. Some recollect about as much of what was 
said and happened in the paroxysm as is remembered of a dream, 
or they retain nothing at all of it in the memory. 

During the attack, external irritation induces no reflex movements, 
or but very slight ones, a fact which will always give rise to a sus- 
picion that it is feigned. When, for instance, a girl tolerates pinching, 
pricking, and blows, without flinching, but sneezes when her nostrils 
are tickled, shivers for an instant when cold water is poured upon her, 
and when burned arouses, complains of pain, there is usually no actual 
disease at the bottom, but only a mental derangement, by means 
of which the nervous child is seeking to excite sympathy. 

Here, again, the course of the entire complaint is very variable. 
Every thing may be completed with a single paroxysm, or several may 
follow each other at greater or lesser intervals, varying from a few 
hours to many days. When the period between two paroxysms is 
very short, and only a few days in duration, the general condition 
barely ever becomes normal, for the patient complains of muscular 
debility, and is whimsical and petulant, and suffers disturbances 
of the digestive organs. The whole afl^ection generally lasts only a 
few weeks or months, and, with the appearance of the menses, com- 
plete recovery is established. Relapses have also been observed in 
this disease, during which the catamenia disappeared, or became 
irregular. A state of extraordinary nutrition, and a disposition to 
obesity, take place in these girls after recovery, especially in the so- 
called spiritualists. 

As regards the sex, the disease, according to a statistical report by 
IVicke, who has collected one hundred and twenty-six cases, attacked 
eighty-eight girls and thirty-eight boys. Of one hundred and seven 
patients in whom the date of the commencement of the disease could 
be ascertained, eighty-four were between the tenth and twentieth 
year of age, and, of these eighty-four, sixty-two were between the 
tenth and sixteenth year. An hereditary disposition is often observed, 
and these patients are almost always brought up by hysterical, eccentric 
mothers. 

In regard to the organic basis of this disease, conjectures can only 
be formed. No certain parts of the brain are aifected in any case, 
otherwise the symptoms would be more constant and uniform ; and in 
no case can an inflammatory exudation or a permanent alteration of 
the form of Ihe brain properly be assumed, because the disease al- 



340 DISEASES OF CHILDREN". 

most always terminates in recovery, and only exceptionally ends 
in paralysis or epilepsy. In fact, the entire activity of the brain has 
simply attained to a high degree, and this disposition sometimes 
manifests itseK most in great irritability of the motor nervous system, 
and sometimes, again, more in an exaltation of the psychical depart- 
ment of the brain. Hasse very fittingly observes : " There is only one 
condition which can be suggested to explain this singular disease, 
namely, sleeping and dreaming." When we bear in mind that such 
manifold, sometimes uniform, sometimes again changeable perform- 
ances transpose the dream into actual action, we have in reality all 
the phenomena of the great St. Vitus's dance. 

"What tends to complete this analogy is, the circumstance that the 
paroxysms begin with a kind of sopor, a stupefaction, and terminate 
with an aAvakening, as from a dream ; so that in chorea major, accord- 
ing to this view, we have nothing else than a potential, lively dream, 
with great irritability of the sensorium. 

The^>>'o^nos«5, inasmuch as the disease is not fatal, must be favor- 
able. The paroxysms almost always cease, although not until after a 
long time, and these persons always retain for life a something singu- 
larly hizaj're, which begets a cautiousness about intercourse with them. 
They sometimes relapse into rehgious enthusiasm, sometimes into 
exalted love-affairs, and are rarely known to make qviiet, sensible 
women. 

Treatment. — There are no medicines which will certainly prevent 
the attacks, not even such as are capable of arresting the disease ; but the 
general state of the system often furnishes opportunities for therapeu- 
tic measures. These girls, as a rule, siiffer from chlorosis and obstinate 
constipation, on accoxmt of which iron and laxatives are usually indi- 
cated. The constipation, in most instances, is so difficult to overcome, 
that powerful drastics have to be employed, with which finally a few 
copious evacuations are obtained. 

The desideratum is always the psychical treatment. If the parox- 
ysms once become the subject of pubhc wonder and town talk, they 
will not cease again for j^ears. It is therefore necessary, first of all, tc 
remove the child to a suitable neighborhood, and at the outbreak of 
the paroxysms remove it from its excited parents into private rooms 
The attacks shovdd be allowed to pass off quietly, and when passed 
they should not be mentioned. Never should the child be told what 
it said and did dm:ing the paroxysm. 

All exciting studies and society should be strictly avoided ; suitable 
bodily exercises and even active exertions have the double advantage 
that the digestion is thereby stimulated and the mind is diverted from 
pernicious fantasies. Sasse holds that the experiments with animal 



DISEASES OF THE NERVOUS SYSTEM. 341 

magnetism, and all experiments generally, are objectionable. In the 
only case which stands as a precept for me, I found cold water of de- 
cided benefit, and the paroxysms ceased entirely after the extremely 
eccentric child was separated from her half-demented mother and 
placed with her sensible grandfather. The fits consisted in this, viz. : 
the girl would suddenly sit down upon the floor, set up a peculiar 
grunting cry, and at the same time revolve with lightning-like rapidity. 
A few glasses of water dashed with force into her face soon brought 
her to her senses again, and after this had been repeated five times 
the paroxysms did not return. 

(5.) Epilepsy, Morbus Sacee, Comitialis, Caducus, Fallsucht, 
Fallij^tg-sickness, Fits. — By epilepsy we understand convulsive 
paroxysms which recur often and are accompanied by sudden abolition 
of consciousness and of the functions of special sense. 

Epilepsy and its causes, the kind and the efifects of the paroxysms, 
are so minutely treated of in the works of special pathology, that it does 
not seem necessary to here give a very exhaustive description, and the 
student may therefore be referred to the excellent delineations found 
in the works of Ganstatt, Romberg^ and Sasse. A few peculiarities 
appertaining to children only will be mentioned here. 

Symptoms. — ^Very often, in adults, remote and almost always near 
premonitions (aura) are observed. The former consist of an altered dis- 
position of the mind, great irritability, headache, vertigo, and a feeling 
of weariness. The latter, which immediately precede the attack, and 
are often so brief that the patients have barely time to prepare them- 
selves for it, consist in headache, giddiness, tinnitus aurium, darkness 
before the eyes, perception of bad odors, trembling, chilliness, oppres- 
sion and palpitation of the heart. In children the remote premonitions 
are mainly unnoticeable, for the reason that the attacks are much more 
frequent, recurring daily, or at least weekly, and therefore no very dis- 
tinct prodromata appear. The near premonitions, the aura, are also 
unheeded by most children, because they pay very little attention to 
themselves generally. Indeed, while quietly playing, the child is usu- 
ally surprised by the paroxysms with such lightning-like rapidity 
that in general no aura can be assumed to exist. 

As regards the paroxysm itself, it almost regularly begins with an 
inarticulate, unnatural cry or moan, and with tears flowing from the 
eyes, by which it is claimed that the commencement of the paroxysm 
must be painful. All subsequent perception of pain, however, is abol- 
ished by the rapidly-sujiervening unconsciousness. During or immedi- 
ately after the cry the child falls down suddenly ; it does not, however. 
first sink down upon the knees and then on the floor, but drops down 
with such force that it seems as if jDrostrated by a violent blow. The 
23 



.342 DISEASES OF CHILDREN. 

direction in which it falls is decided by the position the body was in 
at the time of the seizure, and has no pathognomonic significance. 
Often it is dashed to the ground with such violence that serious inju- 
ries happen to it which may lead to death. It may be assumed with 
tolerable certainly that the more sudden the invasion and the pros- 
tration, the more violent and protracted will be the paroxysm. 

After the child has fallen, the most variable convulsions begin, 
sometimes tonic, sometimes clonic ; sometimes, again, they alternate. 
Epilepsy of children particularly distinguishes itself from that of the 
adult by the inequality of the spasms. While, in adults, especially 
men, one fit runs just the same course as another, in children the 
duration and kind of the convulsions often vary very much ; nor does 
the same group of muscles always participate in the contractions. The 
most frequent phenomena are gnashing of the teeth, tetanic jerkings, 
and contractions of the extremities, contractions of the thumbs, back- 
ward curving of the spine, and the most multiform contortions of the 
muscles of the face and eyes. Still, none of these symptoms are so 
constant as that their absence should render the diagnosis of epilepsy 
doubtful, when the other diagnostic signs correspond. The popular 
supposition, that convulsions in which the thumbs are not contracted 
do not belong to epilepsy, is totally devoid of foundation. This symp- 
tom, though of frequent occurrence, is absent in a considerable number 
of otherwise well-pronounced cases. 

In more violent paroxysms the respiratory muscles also participate, 
in consequence of which the breathing does not go on properly and 
rhythmically, and the expiration in particular, owing to the constant 
contractions of the muscles which ought to be relaxed, becomes labo- 
rious. As a result of this, the thorax becomes distended and the 
respiratory sounds are but feebly heard, if it be at all possible to aus- 
cultate the lungs. The general jactitation of the bod}', and the rattling 
in the throat of the accumulated mucus, however, often make an ex- 
amination of the lungs impracticable. The direct effects of this dis- 
turbance of the circulation are : c^^anosis, swelling of the veins of the 
neck, injection of the eyes, tumefaction of the tongue and entire face, 
and finally even bleeding of the mucous membranes of the conjunctivae, 
nose, and mouth ; not all haemorrhages from the mouth, however, pro- 
ceed from this source. Oftener they are the effects of wounds of the 
tongue inflicted by the teeth during the paroxysm. 

The cardiac muscle seldom participates in the spasms ; the pulse, 
in consequence of the general exertions, is indeed somewhat ac- 
celerated ; still, it is not unrhythmical, and, immediately after the com- 
oletion of the paroxysm, returns to its normal condition. 

The urine and stools pass involuntarily more frequently in children 



DISEASES OF THE NERVOUS SYSTEM. 343 

than in adults, and white or even bloody foam at the mouth is also 
more frequently seen in them than in adults, because the secretion 
of mucus and saliva is generally much more plentiful. In conse- 
quence of the great bodily exertion, a profuse perspiration breaks out 
at the end of the fit, the strong contractions subside, and the children 
wake up as from a dream, and, sighing deeply, stare about bewil- 
dered. Hardly ever do the attacks last longer than five minutes, but 
to the anxious parents the time naturally seems much longer, and is 
unintentionally greatly exaggerated. Although there are many adult 
epileptics who barely suffer one paroxysm a year, the children afflicted 
with this disease are attacked by it at least once a week ; still, no ap- 
proximation to any regularity can be noticed : sometimes long pauses 
ensue, sometimes the paroxysms appear every day, sometimes several 
follow each other at the same hour, so that it was actually thought 
that it had an intermittent character, and quinine was therefore ad- 
ministered — always, of course, without the least effect. Sometimes, 
again, they appear at different times of the day. 

The individual sjntnptoms are not always so conspicuously developed 
as the above delineation declares, and there are also many milder forms 
which have been covered by the name of epileptic vertigo. In this 
form the child does not fall down ; it may stagger somewhat at the 
most, seek to sit down, or, when attacked while walking, continue on 
its way as if in a dream, with rigidly-contracted features. This con- 
dition barely ever lasts longer than a minute, but recurs often during 
the day. Some children have paroxysms of different degrees of sever- 
ity, sometimes only a slight giddiness, sometimes violent convulsive 
fits, with prostration. There are the most multiform gradations, from 
slight giddiness, up to horrible paroxysms, attended with rupture of 
muscles, fractures of bones, and haemorrhages. After a mild attack 
the children recover promptlj^, and eat and play as before, but after a 
severe one they sink into a long and profound sleep, from which they 
awake with headache and fatigue, which generally last for several days. 

During the intervals the state of the health differs according to the 
duration, severity, and frequency, of the paroxysm. Some children, 
who only suffer from tHe milder form, retain their healthy appearance, 
and continue to develop both bodily and mentally ; others, however, 
especially after an epilepsy of several years' duration, acqmre a brut- 
ish expression of countenance, become morose, choleric, ravenous, and 
retrograde instead of progress in their mental development. Their 
physical development is also arrested, and they ultimately degenerate 
into complete cretins ; cicatrices and contusions, the effects of the falls, 
are found on the body ; the teeth, from the constant grinding, are worn 
off ; and the tongue is fissured by the wounds it has received. 



3^^ DISEASES OF CHILDREN. 

But milder forms of the disease are borne throughout life without 
any iU consequences, as is shown by the well-known fact that many 
persons eminent for their mental endowments have suffered from 
epilepsy to the end of their lives. The most prominent of this class ot 
epileptics are : Julius Gmsar, Mohammed, Charles V., Petrarch, Fa- 
Uus Columna, Eousseau, and Napoleon I. 

The course of epilepsy is decidedly chronic, for the patients retam 
it for life and take it with them to the grave ; the commencement is 
eminently acute, for in most cases very uncertain premomtions pre- 
cede it and the disease can be diagnosticated only after the first 
paroxysm has appeared. The younger the child, the more frequent 
the paroxysms; and they diminish in frequency with advancing age 
till about the period of puberty, when they again become frequent, 
and so continue for more or less time, and finally assume a more con- 
stant form, and the intervals become more uniform. The disease is 
decidedly aggravated by onanism, sphituous drmks, and aU kinds of 
mental excitement. No scientific connection can be demonstrated to 
exist between epilepsy and the growth and decline of the moon a 
very common supposition among lay people. On the other hand, the 
climate, or perhaps only the temperature, is not wholly devoid of in- 
fluence in some cases. I am acquainted ^vith a man who m the co d 
mnter months suffers from a mild epilepsy, but in summer is entirely 
free from it. For the last two years he has spent the winter m Al- 
giers, and has been free from the attacks. 

Epilepsy is arrested during acute febrile diseases, but is exacer- 
bated by chronic affections, such as helminthia, constipation, and neu- 
ralgia. The influence it exercises upon the mental functions has al- 
ready been spoken of above. 

The usual termmation is, in fact, in death. Epilepsy, it is true, 
does not prevent the child from growing up to thirty or forty years 
of ao-e but it appears from statistics that it very seldom outlives 
this age. Serious cases usually run into other cerebral diseases, such 
as cerebral apoplexia, mania, or imbecihty, which are soon fatal. 
Recovery is a very rare occurrence ; less so, however, m children than 
in adults. In children, epilepsy has been seen to disappear after the 
cutting of the four molar teeth, and sometimes upon change of resi- 
dence. Additional minutiae upon this point are to be found in the 
section on etiology. Recovery either takes place suddenly or gra- 
dually. The last paroxysm is either just as violent as the previous 
one, or the fits disappear gradatim, and first merge into mild epileptic 
vertigo, and finally disappear. 

Etiology Difficult as it is, in most cases, to fathom the true 

cause of epilepsy, a particularly careful examination, and close inspeo- 



DISEASES OF THE NERVOUS SYSTEM. 



345 



tion of the body, must nevertheless be practised, for it may discover 
something upon which to found a rational treatment. The form of 
the attack furnishes little or no data for the etiology. Even the kind 
of aura preceding the attack is not available in children, since in gen- 
eral it is very short, and is immediately forgotten after the fit. 

As regards the age^ epilepsy spares none. Young children in gen- 
eral rarely suffer from true epilepsy, as we might expect, if the more 
frequent eclampsia be regarded as a distinct disease. Eclampsia is 
easily distinguished from the disease under consideration, by the fact 
that it almost always occurs at the breaking out of an acute affection 
only ; that the general condition of the patient, after the termination 
of the convulsions, is not restored ; and that it is often fatal, while 
epileptic attacks are almost always devoid of danger. 

According to a statistical compilation by JBeau, two hundred and 
eleven epileptics present the following history : 



Congenital epilepsy 17 

From birth up to 6 years of age 22 

" beginning of 6th to 12th year.. 43 

" " r2th to 16th " 49 

" " 16th to 20th " 17 



From beginning of 20th to 30th year 29 

" " 30th to 40th " 12 

" " 40th to 50th " 15 

" " 50th to 60th " 5 

" " 60th to 61st " 1 



It will be seen that two-thirds of these patients, at the invasion of 
the disease, had not attained the sixteenth year. 

As regards the sex, it is generally assumed that in adults more wo- 
men are epileptic than men. I am not aware of any tabular compilations 
of epilepsy in children arranged according to the sex, but, from the 
cases which I have so far observed, the statement above given as to 
adults will not apply to children, for I can recall to mind more epilep- 
tic boys than girls. 

The hereditary nature of epilepsy is generally acknowledged, even 
among lay people. It is by no means necessary that the inherited 
epilepsy should also be congenital, i. e., occur immediately after birth ; 
it may remain latent for a long time, and only come on at the period 
of puberty, or even still later. Congenital epilepsy is especially ob- 
served when epileptic mothers suffered from frequent paroxysms dur- 
ing pregnancy. In children under one j'ear of age, it is very difficult 
to distinguish it from eclampsia, or general convulsions, and it is only 
characterized by its chronic course, and by its not being followed by 
any acute disease after the fit has passed off. 

Epilepsy sometimes overleaps a whole generation, and appears in 
the second with all its former severity, or it attacks only portions of 
the descendants, sometimes the male, sometimes the female. 

Besides the causes already assigned, there are many others men- 



346 DISEASES OF CHILDREN. 

tioned in the text-books ; few of tliem, however, are demonstrable. 
Thus, for example, it is claimed that great mental excitement, espe- 
cially from fright or anger, is a very potent cause. If this were the 
case, the great majority of persons ought to be epileptics. Various 
forms of epilepsy, according to the locality of the aura, have been dis- 
tinguished, such as epilepsia spinalis, thoracica, abdominahs, nephri- 
tica, genitalis, and peripherica, without it being possible, however, to 
confirtn these varieties by post-morteyn appearances. 

An epilepsy excited by tuberculosis chiefly occurs in children. A 
large tubercle in the bronchial glands, or in the brain, an hypertrophied 
tuberculous lymphatic gland exerting a pressure upon the circum- 
jacent nerves, are some of the supposed causes of epilepsy. In rare 
cases, cr_)^torchidismus is the alleged cause. These recover after the 
testicle has descended, or, if arrested in the canalis vaginaHs, after the 
testicle is removed. Of the peripheral causes, the most frequent is the 
eruption of a cuspid or wisdom tooth, after which a recovery has been 
seen to ensue. Epilepsy is repeatedly reported to have been cured by 
the excision of a cicatrix. These instances, however, are very rare, al- 
though all epileptics, since that fact first became known, are closely 
examined for cicatrices, which, when found, are excised with the best 
of hopes ; still, the paroxysms are generally in no way affected by this 
operation. 

The post-mortem examinations of epileptics furnish no uniform 
results whatever. They sometimes turn out to be totally negative. 
In many cases the most variable lesions of the brain are found, atrophy 
and hypertrophy, induration and softening, plastic and serous exuda- 
tions on the meninges, ha3morrhages, tubercles and abscesses in the 
substance, hernia, exostosis, caries or necrosis of the cranial bones. 
In congenital epileptics, in addition, there are found asymetrical cranial 
bones, flattening of the forehead, a broad or pointed occiput ; the bones 
of the skull are sometimes remarkably tliickened ; sometimes, again, 
attenuated. Elliotson is perfectly correct when he says that this kind 
of cranial bones does not necessarily produce epilepsy. It is, how- 
ever, certain that this evil very frequently occurs in imperfect develop- 
ment of the brain. In the older medical works, vascular congestions 
of the brain and spinal cord play an important part, but lately these 
anomalies of the distribution of the vessels have justly come to be re- 
garded as phenomena occurring at the time of, or even after death. 
The posirm,ortem, appearances in the other organs may vary still more 
than those of the brain ; in other words, epileptics may perish not 
only from the effects of this chronic malady, but also from all pos- 
sible acute and chronic diseases. On carefully dissecting the nervous 
centres, neuromata have also been frequently foimd. 



DISEASES OF THE NERVOUS SYSTEM. 347 

Diagnosis. — The main difficulty in the diagnosis in female adults is 
to distinguish hysterical attacks from the truly epileptic. But that is 
chiefly and especially accomplished by the circumstances that, in the 
former, consciousness is not wholly abolished, and for that reason also 
no prostration and no wounds from the teeth occur. In cliildren it is 
not hysteria but eclampsia that may be confounded with epilepsy. It is 
impossible to distinguish an eclamptic fit by itself from an epUeptic one, 
but the condition by which it is succeeded furnishes a correct differen- 
tial sign. After an eclamptic attack, the child never feels perfectly 
well ; it is always feverish, suffers from an acute exanthema, or some 
other acute disease, or vomits at least the undigested contents of the 
stomach. Epileptic children are perfectly well on the same, or, at 
least, on the next day, and are free from all signs of fever. 

Spoiled children sometimes also take it into their heads to feign 
epilepsy, in order to escape corporeal chastisement, for they observe 
that truly epileptic children are never very severely punished. Those 
who attend large schools, and inmates of educational institutions, have 
great facilities for acquiring this simulation, for they have frequent 
opportunities to observe epileptic children. It is not always easy to 
distinguish the feigned from the genuine epilepsy in children who 
are refined and possess imitative talent. Under no circumstances 
should simulation be assumed unconditionally, so long as there is no 
positive proof. The tutors should be instructed to treat such children 
with the same indulgence as they would treat genuine epileptics, and 
should rather allow themselves to be imposed upon for a time than 
to aggravate the condition of a really sick child by undue severity. 
It is, however, scarcely possible that the impostors will ever succeed in 
imitating the strong turgescence of the face during the paroxysms, 
and still less the subsequent abnormal pallor. It is very difficult, 
according to Mare^ to extend the thumbs and open the hands of a 
genuine epileptic, but, after this has once been accomplished, the hand 
will stay open. The feigner is not aware of this peculiarity, and will 
shut his fist again as soon as he feels no resistance. In regard to this 
sign, however, a great number of epileptics have yet to be examined 
before undoubted value can be awarded to it. 

Treatment. — The practical therapeutics of epilepsy is perhaps the 
most extensive, and at the same time most unprofitable of any disease. 
All possible remedies are administered, and such brilliant success is 
ascribed to them, that it requires great medical skepticism to doubt 
them. The supposed good effects of many remedies may also be 
based upon error, or at least self-deception and imperfect observa- 
tion, but a correct inference as to their value is rendered still more 
difficult by the circumstance that, from all remedies, no matter what 



348 DISEASES OF CHILDREN. 

may be their chemical composition, a decided improvement is always 
obtained at first. This observation, first made by Esquirol^ has since 
been confirmed by great numbers of observers, and clearly shows 
that the psychical state possesses great influence upon the morbid 
process. 

The treatment itself comprises (1), the prophylactic; (2), the re- 
moval of the cause ; (3), the use of specifics ; and (4), a general bodily 
and mental hygiene. 

(ad 1.) The irrophylactic treatment, on account of the acknowl- 
edged hereditary character of the disease, consists in restraining epi- 
leptics from marrying, and in preventing an epileptic mother from suck- 
ling ber child, and in treating the children of epileptic parents with the 
utmost possible forbearance. Over-stimulation of the nervous system 
by early and exacting studies, or by exciting impressions, such as scold- 
ings, chastisements, ghost-stories, etc., is to be avoided. 

(ad 2.) The treatment directed to the cause, w^here the cause can 
really be fathomed, is by far the most favorable. But, unfortunately, 
it is much less possible to discover the true cause than is usually 
supposed, for the statements of the relatives, of a fall, fright, or of a 
grave sickness recovered from, etc., should be received vrith the ut- 
most caution. First of all, the child should be undressed, and every 
part of the body subjected to a critical examination ; the assertion of 
the relatives, that the entire body is normally formed, should never in- 
duce us to forego this examination. By it a tumor pressing upon a 
nerve, a cicatrix involving a nerve, or a foreign encysted body, has 
often been discovered, located in the course of the peripheral nerves, 
whose removal was followed by the disappearance of the epilep- 
tic convulsions. It is even stated that epilepsy has been cured by the 
excision of corns, and extraction of carious teeth (?). In this peripheral 
epilepsy, the exsection of the affected nerve is attended by the surest 
effects. The condition of the brain and its adjacent parts, of course, 
deserves special attention. The cranial bones should be carefully ex- 
amined for depressions, otorrhoea, syphilitic exostosis, etc. ; chronic 
congestive conditions of the brain should be relieved by revulsions 
to the alimentary canal, or by derivatives, and counter-irritants, such 
as vesicants, irritating ointments, setons in the nape of the neck, and 
even moxas. With tliis object in view, the carotids have even been 
tied, and recently a trial of compressing them has been made. Both 
these measures, however, proved ineffectual. Trephining of the for- 
merly injured cranial bones is also indicated, in cases where the par- 
oxysms do not improve after the cicatrix of the scalp has been ex- 
cised. Tissot thinks so highly of this operation, that he recommends 
it to be tried in all desperate cases. 



DISEASES OF THE NERVOUS SYSTEM. 349 

Wten worms are present, they are to be removed by the methods 
suggested in the chapter on " Intestinal Worms." Disposition to con- 
stipation should be obviated by frequently-repeated clysters, or aperi- 
ent waters. The genitals should be closely examined for evidences of 
onanism. Rapidly-cured eruptions of the skin and arrested habitual 
sweatings may sometimes be reestablished. 

The treatme/nt of the paroxysm itself essentially consists in pro- 
tecting the body against injury. The furniture of the room occupied 
by the patient should not present sharp, exposed corners, the stove 
should be guarded, the floor covered with carpets, and the couch should 
be low, so that the patients may not sustain serious injury should they 
happen to fall from it during their nocturnal attacks. They should 
never be left without surveillance. All restraint at the commence- 
ment of an attack is injurious, and tight garments should be loosened. 
All measures employed during the paroxysm, such as frictions, sprink- 
ling of cold water, compression of the carotids, magnetism, inhalation 
of irritating gases, opening of the thumbs, and tying the face, how- 
ever popular these may be, are either useless or injurious. 

The attempts in a protracted aura to prevent the fit itself have not 
heretofore proved very successful. On the whole, only those parox- 
ysms which are of peripheral origin may possibly be arrested. The 
remedy consists in tying the affected limb tightly with a strong liga- 
ture, which is gradually slackened after several hours. By this means 
it is certainly possible in some cases to prevent the paroxysm alto- 
gether ; in others, however, it causes the utmost dread and apprehen- 
sion, and the patients insist upon the speedy removal of the ligature, 
preferring to suifer the convulsions. Children generally rally very 
rapidly after the fit, so that there seems to be no occasion for an after- 
treatment. Sopor, a feehng of weariness or nausea, which occasionally 
remain behind for some time, are quickly relieved by a sinapism or a 
derivative foot-bath. 

(ad 3.) The anti-epileptic specific remedies have lately become so 
fearfully numerous, that the denomination " specifica " may be re- 
garded as a veritable disgrace to the physician. It would be of no 
use to copy here the whole list of the anti-epileptica that were and 
still are used. Those most extensively employed only will be briefly 
mentioned. 

For the treatment of the recent attacks the following remedies, ac- 
cording to JK^ohler, are appropriate : 

(1.) Rad. artemisije vulgar., 10 to 20 grs. of the fresh powder, 
given as short a time before the fit as possible. 

(2.) Rad. valerianaj, daily, 3ss to 3j of the fresh powder. 

(3.) Florea zinci, gr. j to x, or in as large doses as possible, is recom- 



350 DISEASES OF CHILDREN. 

mended by many physicians, especially Serpin. The treatment should 
be continued for three months. Valerianate of zinc is, in fact, a com- 
bination of two remedies for epilepsy, but the effects of the zinc do 
not seem to be improved in the least by the valerian. Others prefer 
the sulphate of zinc, and give it in j to v grain doses pro die. 

The following remedies are employed in older cases, and in which 
those just described have proved ineffectual : 

(1.) Ammoniate of copper and the various preparations of copper 
with which, owing to their nauseating properties, it is not usually pos- 
sible to go beyond -J, at the most \ grain doses. 

(2.) Argent, nitrat. is recommended by many physicians, especially 
by Heim. In children it must be given in |- to 1 grain daily for years. 
There seems to be no very great danger of the skin becoming gray 
from it, as that happens in only a very few patients. I, for instance, 
notwithstanding a most extensive employment of this remedy, have 
never yet observed that result. The great precaution that is taken to 
introduce the nitrate of silver, as such, into the stomach, is probably 
superfluous, for the combinations of chlorine which are constantly 
present in the gastric secretions must certainly convert it quickly into 
a chloride. 

(3.) Mercury, internally in the form of calomel, sublimate, or cmna- 
bar, or externally in the form of blue ointment, is only indicated when 
there is a suspicion of the presence of Tophi syphilitici. It, however, 
must not be forgotten that, on account of its consecutive constitutional 
effects, it may prove very injurious. 

(4.) The additional metallic remedies to be mentioned are, acetate 
of lead, oxide of zinc, nitrate of bismuth, the preparations of iron, 
manganese, and arsenic. 

(5.) The narcotics have been extensively employed, and are in- 
variably found in the numerous secret remedies. No certain curative 
effect has been derived from opium, but a rapidly-developed imbecihty 
has very often indeed been observed from its use. Rad. belladonnae, 
and latterly atropine in gr. -gL- to ^q, chloroform, ether, ext. stramonii, 
hyoscyamus, digitalis, agaricus muscarius, narcissus, pseudo-narcissus, 
nux vomica, and strychnine (gr. -g^ to |- pro die), have been repeatedly 
recommended. 

(6.) Finally, there is yet a list of vegetable and other kind of 
remedies from the various classes of the materia medica : selium 
palustre, indigo, viscum quercinum, sedura acre, folia aurantiorum, 
radix paeoniae, cotyledon umbilicus, Scutellaria geniculata, assafoetida, 
moschus, castoreum, camphor, amber, cinchona and its preparations, 
rad. dictami albi, pepper-corn, turpentine, Dipel's oil, phosphorus, and 
the mineral acids. 



DISEASES OF THE NERVOUS SYSTEM. 35I 

(ad 4.) The general bodily and mental hygiene is of great impor- 
tance. The diet should not be too nutritious, and alcoholics should be 
prohibited altogether, for in many patients a fit is induced by indiges- 
tion, and, still more surely by a use of alcoholic drinks. Constipation 
should never be permitted. It is of especial benefit, in all cases, to 
stimulate the functions of the skin by cold and warm baths, so as 
to produce copious perspiration. Bodily exercise, especially in the 
open air — for example, in garden and field — often efi'ects a complete 
cure. Of the bodily exertions, only such, of course, are to be chosen 
as will not of themselves induce a paroxysm ; riding and swimming, 
for example, can hardly be recommended. Travelling and change of 
climate, particularly changing a colder for a warmer, often bring 
about a suspension of the paroxysms, to which the diversion and the 
agreeable state of tbe mind which result from some travels may con- 
tribute not a little. It is a well-known fact that cMldren are seldom 
attacked while playing, or when occupied, but only at niglit, or when 
they sit morose and idle. 

They should not be encouraged to forego mental exertions, for the 
mind, if not exercised, sinks into a state of unhealthy torpor. But 
the hours of study should be so arranged as to allow sufficient inter- 
vals of rest ; and they should be taught in such a manner as to inter- 
est them in their studies, and thus render learning comparatively easy 
— a fact, however, every tutor does not know, and a result he does 
not know how to accomplish. These children should not, if possible, 
be sent to the public schools, for most of them learn much slower than 
healthy children, and, on account of the fits, are feared and even de- 
rided by the latter. Under these circumstances the mental depression 
becomes considerably aggravated, and it is a serious detriment to a 
person, in after-life, that his previous affliction should be generally 
known, although he may have been subsequently cured of it. 

[Of all the remedies that have been recommended for this disease 
none have served me so well as zinci sulph. in gradually increasing 
doses till nausea is produced ; the dose is then diminished and 
after a few days again increased ; and bromide of potassium in full 
doses continued for a long time, and then given less frequently.] 

APPENDIX. 

A.—8UGTU8 VOLUPTABILIS {Voluptuary Indulgence). 

There are children who have a habit of sucking their thumbs, 
which seems to afford them an inordinate amount of enjoyment. 
liindner, of Pesth, has lately described this condition very fully. 
In Middle and Southern Germany children addicted to this practice 
are in popular parlance called " Ltitschers," or " thumb-suckers." 



352 DISEASES OF CHILDREN. 

By that is understood an irresistible desire to suck at the fingers, 
back of the hand, arms, and in rare instances even the toes. Other 
children constantly make suction-motions with their lips and tongue 
while fingering the lobe of the ear, punctum voluptahile. 

Such children sleejiing with their mothers or other persons are 
apt to practise the habit of sucking upon their bed-fellows, which 
is exceedingly annoying to them. Indeed, there are children who 
carry this practice of thumb-sucking to such a pitch that it is a 
source of pain to themselves and an annoyance to others. Mention 
might be made here of the habitual biting of the nails, whicli in 
some individuals appears to be hereditary. The consequences of the 
above-mentioned evil are scoliosis of the spinal column, produced 
by the prolonged twisting of the head and malposition of the arm, 
misshapen lips, alterations of form of the lower jaw, and irregu- 
larity of the teeth. Many children addicted to this habit remain 
backward in their mental development ; most idiots, in fact, actually 
practise thumb-sucking or habits equally objectionable. That chil- 
dren guilty of thumb-sucking readily become masturbators, as one 
would naturally infer, has not proved to be the case, for out of sixty- 
nine cases compiled by Lindner four only had contracted that vice. 

Etiology. — The causes of these peculiar conditions are not easily 
explainable. Some authors maintain that it is produced by the 
sucking-rag or sugar-teat which is very often employed to quiet 
crying infants. But, according to Lindner, out of sixty-nine chil- 
dren, the progeny of fifty-four families, in three only had the suck- 
ing-rag been used in the first year of life. In two families that I 
attend, where the biting of finger-nails is found to be hereditary, 
there is also simultaneously a congenital disposition to mental alien- 
ation. 

These faulty habits persist, notwithstanding all the efforts that 
are made by those who have the training of these children ; neither 
kindness nor harsh measures seem to be of use. After several 
years, the habit generally ceased of itself, after all efforts at correc- 
tion had been abandoned. The ridicule of their comrades and the 
awakened vanity no doubt lead these children to break themselves 
of it. 

As the tendency to practise thumb-sucking is particularly strong 
both directly before falling asleep and immediately after waking, 
it is best not to put children too early to bed nor allow them to lie 
awake in bed in the morning. All sensual indulgences suggesting 
or favoring this bad habit must be strictly prevented. That this 
fault cannot be corrected by the administration of medicine, it is 
scarcely necessary to say. 



DISEASES OF THE NEKVOUS SYSTEM. 353 

B.— DISEASES OF TEE MIND. 

In children, imhecility and idlotism predominantly occur. It is 
necessary to discriminate between real idiotism and arrested or re- 
tarded development of the mind, although there certainly are steps 
of transition where this distinction is difficult to make. The de- 
velopment of the body, also, in real idiots, is always visibly retarded, 
"while many children, with extremely feeble mental endowments, 
the so-called en/ants arrieres, corporeally thrive all the more. 
Marked abnormalities are also always detected in the skulls of idiots, 
which are due to the smallness of the brain. The circumference of 
the skull is small, the head is compressed or pointed from before 
backward, or from side to side, in contrast to endemic cretinism, 
which is found most typically marked in some of the valleys of the 
Tyrol, and which manifests itself by the form of the skull approach- 
ing more that of a square, and by hypertrophy of the bones, 

Idiotism, depending upon smallness of the brain, occurs sporadi- 
cally, and seems to be promoted by intermarriage. Out of one hun- 
dred idiots, according to statistical compilations by £emis, of Ken- 
tucky, fifteen were the progeny of marriages that had been formed 
between cousins. Cretinism occurs chiefly in narrow, dark valleys, 
and is very seldom observed on the plains. Whether coitus during 
intoxication will also produce idiotic children, is much doubted, for, 
if this were the case, these would undoubtedly be more numerous. 

Symptoms. — The degree of idiotism varies exceedingly. In the 
extreme degree, all mental action is defective, and the organs of 
sense perform their functions very imperfectly. Deafness is fre- 
quent. Complete idiots are incapable of learning to speak ; they 
do not even attempt, by stammerings or mutterings, to make them- 
selves understood ; the cry is rough and monotonous. The children 
learn to sit very late, but never to walk. They swallow greedily 
the food allowed them, without tasting it ; they allow the urine 
and stools to pass off uncontrolled. In consequence of this torpor, 
the muscles of the body become atrophied, and the integument cov- 
ered with ulcers, from pressure and filth. Fortunately, most of 
these individuals die of convulsions during the first dentition, and 
never attain to puberty. 

In those cases of less severity the children learn to stammer and 
to walk, and instinctive movements also take place. They call for 
food and drink, recognize the objects by which they are surrounded, 
and become fond of cleanliness. They also, in some cases, learn to 
perform simple physical acts, in the same manner as educated ani- 
mals. But their gait always remains unsteady, the expression of the 
countenance silly, and the muscular system weak, while convulsions. 



354 DISEASES OF CHILDREN. 

and subsequently paralysis, often ensue. These cbildren seldom live 
past the first and second dentition, and at best attain to no great age. 

In the mildest degree — that of simple mental debility — the small- 
ness of the head is not very striking, the body develops itself, al- 
though slowly, to its almost normal formation, and one or another 
sense only remains blunted, but asthenoiiia, or deaf-mutism, also 
makes these individuals useless members of the human family. 

Treatment. — Defective formation of the brain, of course, can 
never be the subject of direct treatment, but, by a proper rearing 
and education, something may possibly be accomplished in waking 
up the feeble mental powers. In order to keep such children alive 
as long as possible, the first requirement is to habituate them to 
cleanliness, without which, ulceration of the skin, quickly followed 
by atrophy, results. It is best to remove these children from the 
paternal home, for the long period of time and the rigid surveil- 
lance requisite for their improvement are seldom to be found in 
their own. Then it is a question whether it is possible, by inces- 
sant, careful observation, finally to discover the existence of one or 
more faculties, and to persevere in their progressive cultivation and 
improvement. The main difficulties encountered in this are the in- 
dolence and the complete abstraction of the idiots. The education 
of these poor creatures requires an almost superhuman patience — 
such, indeed, as is very seldom found, their uncleanly habits adding 
much to these difficulties. 

Other diseases of the mind, in young children, are very rare, 
but, after the completion of the second dentition, they are oftener 
observed. Out of one thousand cases of insanity, according to sta- 
tistical compilations of cases that have occurred in Bicetre during 
three years, on an average, ten were youthful idiots, epileptics and 
imbeciles not included. From a most careful inspection of these 
cases, it was found that, aside from the hereditary disposition and 
previous disease, improper education and want of care were the 
chief causes of their condition. 

Le Paidmier, the compiler of these statistics, distinguishes three 
forms of mania in the young : (1), maniacal exaltation ; (2), in- 
sanity ; and (3), madness. 

In the first form, the faculty of judgment is not completely 
abolished ; still, a marked deficiency of reflective faculty exists. 
The patients are talkative, excited, vain ; are a prey to foolish dis- 
sipations, as well as shameless and violent acts. In the second de- 
gree, insanity, the confusion of ideas is more pronounced ; the pa- 
tient incessantly jumps from one subject to another, or from one 
extreme of feeling to another. In the third and highest form, all 
association of ideas is abolished, and panphobia and mania, the signs 



DISEASES OF THE NERVOUS SYSTEM. 355 

of commencing paralysis and imbecility, not unfrequently become 
superadded. Independent of the real symptoms of mania, psychosis 
in the youth is often complicated with chorea, or a kind of cata- 
lepsy, which comes on at uncertain intervals, and in paroxysms of 
greater or less duration. West speaks of children affected with 
mental diseases, who were only six or seven years old ; generally, 
however, the majority of these have attained the tenth year, and 
are approaching puberty. 

The prognosis, in general, is more favorable than in adult de- 
mentia, but, according to Delasiauve, there is always a great tend- 
ency to relapses. 

It has been observed that, the longer the stadium of premoni- 
tion lasts, the worse is the 23rognosis. We are justified in the con- 
clusion that, although the cure often appears permanent, a psychical 
disturbance occurring in childhood is always to be regarded as a 
very serious disease. 

The treatment in the paternal house is but very seldom effectual, 
and hence it is absolutely necessary to have these patients removed 
to an asylum. 

G.— HIGHER ORGANS OF SENSE. 
I.— Sight. 

Ophthalmology has grown into such a perfect specialty that a 
general treatise on the diseases of children need not comprise a 
detailed delineation of the diseases of the eye. The student may 
therefore be referred to the works on ophthalmology for informa- 
tion upon this subject, and only the congenital diseases of the eye, 
and those that occur in infants especially, will here receive a very 
cursory description. 

(1.) Epicanthus. — By epicanthus is understood an imsightly 
gathering of integument in the region of the root of the nose, tow- 
ard the inner angle of the eye, a semilunar fold covering the angle 
of the eye in the form of a pocket. The upper point of this cres- 
cent is found at the root of the nose ; the lower is lost in the in- 
tegument of the cheek. The root of the nose is always very flat, 
and the nasal bones meet each other at an obtuse angle, so that the 
folds of the integument, elevated by the accumulation of adipose 
substance, are on a level with the depressed nose. The pocket 
never extends so far as to obscure the field of vision, but completely 
covers the inner angle of the eye, and may reach to the inner mar- 
gin of the cornea. The cause of this deformity, according to V. 
Amnion, is a flat dorsum of the nose, and a lax adhesion of the in- 
tegument to the nasal and lachrymal bones. This etiology, how- 
ever, is not very satisfactory, for there are also children with 



356 DISEASES OF CHILDREN. 

depressed noses, and easily displaceable integument, who exhibit no 
such fold whatever. 

Epicanthus is always congenital and bilateral, but it may be 
larger on one side than upon the other. When the skin on the dor- 
sum of the nose is raised up with two fingers into a fold, the de- 
formity disappears, and this fact suggests the proper operative 
procedure. As the epicanthus is usually seen in the new-born child, 
and never in the adult, it follows that, with increasing growth, it 
must become smaller and ultimately disappear. This deformity, 
where it does not thus disappear early, may be remedied by excising 
a longitudinal fold of skin from the dorsum of the nose, and uniting 
the edges of the wound by suture. 

(2.) Cyclopia — Moxophthalmia. — Total defect of the orbits 
occurs in monstrosities, the frontal bone continues down into the 
upper jaw, and in the bone shallow grooves only exist in place of the 
orbit. In defective formation of the brain (hemicephalia), the bones 
of the orbit are only rudimentarily formed, and its upper border, in 
particular, is very much diminished, and very close to the optic 
foramen. Cyclopia finally is likewise only possible in defective orb- 
ital bones. Here the ethmoid, the lachrymal, and the nasal bones 
are absent, and the sphenoid bone is also altered in shape. These 
are mere malformations, met with only in monstrosities incapable of 
living, and are, clinically, of no interest. 

(3.) Malformations of the Eyeball. — (a.) Coloboma iridis s. 
iridoschisma, a congenital splitting of the iris, is a condition similar 
to that of harelip ; the fissure in most cases runs downward, and the 
deformity is more frequently seen in both eyes than in one only. Its 
edges converge toward the ciliary border, and are but seldom par- 
allel or diverging, so that the pupil mostly assumes the form of a 
pear, with the base directed downaward. In rare instances a fissure 
in the large circle of the iris alone is observed, so that a normally 
round pupil, with a peripheral, triangular opening, separated from 
the pupil by an iris-colored transverse band, is present. By the 
alternate presence and absence of light in front of a coloboma, its 
margins may be seen to shorten and elongate like the contractions 
and dilatations of the pupil, but this closure never is great even un- 
der the influence of a strong light. This condition has often been 
observed as an hereditary one. The complications occumng with 
it are : microphthalmus, ovale cornece, central lenticular cataract, 
harelip, hypospadias, cerebral defects, and coloboma of the upper 
eyelids. The latter is only observed on the upper eyelid, and con- 
sists in a narrow fissure of the tarsal cartilage, in which the exter- 
nal integument is not correspondingly fissured. There is no embryo- 
logical explanation for this malformation, such, for instance, as is 



DISEASES OF THE NERVOUS SYSTEM. 357 

readily found for harelip, for the upper eyelid at no time of embry- 
onic life consists of two parts. 

(b.) Irideremia. — Total or partial congenital absence of the iris is 
always observed simultaneously on both sides, a single instance, re- 
ported by Moriso7i, excepted. Either no iris, or but a rudimentary 
strip only, is seen. Here the pupil properly never presents the back- 
ground of the healthy eye. In certain positions, with reference to 
the light, they glisten like the eyes of cats. This also hajDpens occa- 
sionally in large colobomas. Usually the cornea is not normal, it is 
oblong, or gradually merges into the sclera, and the lens may like- 
wise be opaque. Such children naturally are always short-sighted, 
and, on account of the too great amount of light admitted, con- 
stantly contract their eyelids, by which means they obtain a sort of 
substitute for the deficiency of the pupils. A constant rolling of 
the balls (nystagmus oscillatorius and rotatorius), on account of this 
incompleteness of the power of vision, also becomes superadded. 
This malformation, according to Arlt, has never led to blindness by 
paralysis of the retina, but inflammation of the cornea and conjunc- 
tiva, and also gradual lenticular opacity, very frequently ensue. 

The treatment must be confined to efforts to control the amount 
of light admitted to the eye, by the use of blue glasses or artificial 
diaphragms. 

(c.) Cataract. — Cataracta nuclearis is a sharply-defined grayish- 
white point, of the size of a poppy-seed, in the centre of the lens, 
around which a brighter zone is sometimes observed. It is mostly 
met with in both eyes, and is often complicated with absence of the 
iris or coloboma. In addition, white points also develop themselves 
in children after birth, in the lens or its capsule, and send out white 
radiating stripes, thereby obscuring the vision, but not entirely de- 
stroying it, as the opacity of the lens never becomes general. 

(d.) Atresia pujnllaris congenita. — Congenital closure of the 
pupil is due to an anomalous continuance of the pupillary membrane 
after birth. 

According to JBischoff, the membrana-capsulo-pupillaris, and the 
membrana pupillaris together, form a vasculo-membranous sac, 
which, issuing from the posterior circumference of the lenticular 
capsule, extends through the posterior chamber of the eye as far as 
the iris ; here it is connected with the iris by vessels, and by its 
anterior wall represents the membrana pupillaris. 

But this sac originally seems to envelop the lens and its capsule 
only, for the lens at an early period lies closely behind the cornea, 
and no iris as yet is present. But, when the iris begins to develop 
itself, it becomes imited to the anterior part of this sac, holds the 
united membrane back as the lens recedes after the formation of the 
24 



358 DISEASES OF CHILDREN. 

anterior chamber of the eye, and thus a true membrane originates 
before the pupil, the membrana pupillaris. 

This membrane, it is said, begins to disappear from the seventh 
month, and should be wholly gone at birth, but often it remains as a 
transparent membrane, with few or no vessels, for a long time yet 
after birth. 

There are a number of cases in which, according to Stellwag von 
Carion, the pupillary membrane has been seen in its integrity in new- 
born children, and even in adults. It is seen as a fine, grayish-white 
membrane, accurately expanded on a level with the pupil, closing it, 
thereby destroying the power of sight to some extent, and making 
the iris immovable. In some instances this membrane is perforated, 
or a few shreds only hang on the pupillary borders. Stellwag warns 
us against the possibility of confounding this condition with organized 
exudation and capsular cataract, and considers the prognosis of con- 
genital closure of the pupil as favorable. Nature, in time, makes 
amends for what it was remiss in at birth. The action of the iris 
muscle lacerates the membrane, and the torn fragments are gradually 
absorbed. 

The evil, on the whole, is very rare, and many busy oculists have 
never met with it. 

So much in regard to congenital malformation of the eye. The 
period of infancy is decidedly predisposed to diseases of the eye, and 
we should have to compile a complete treatise on ophthalmology if all 
the morbid conditions occurring in it were here to be described. 

Two affections of the eye, specially belonging to children, blennor- 
rhcea of the new-born child, and oedematous conjunctivitis during den- 
tition, have already been minutely treated of in their appropriate chap 
ters, pages 76 and 110. Scrofulous affections of the eye in children 
will be described in a future chapter on scrofula. 

The other diseases of the eye differ little in any respect from 
those that occur in the adult, and consequently may be properly 
omitted here. 

It should be observed that, in children, the outer structures gen- 
erally, and especially the conjunctiva, the lids, and muscular appara- 
tus, become diseased, while adults more frequently suffer from morbid 
alterations of the inner parts of the eye, the iris, lens, vitreous hu- 
mor, choroid, and retina, 

II.— Hearing. 

I. — Malformation of the ORGAif of Hearing. — (a.) Absence 
of the Auricles (Ears), Defectus Auriculce. — Occasionally an abnor- 
mal congenital smallness, shrinking, or a complete absence of the 



DISEASES OF THE NERVOUS SYSTEM. 359 

auricle, upon one or bcith sides, occurs, and is usually complicated 
with malformations of other organs. 

Aside from the very striking deformity, this defect also causes a 
detriment to the hearing, although it is but a slight one. 

If any treatment to mask the deformity is to be instituted, the 
first measure should be properly shaping the hair so as to cover the 
ear. If for any reason this be not available, there will be no other 
resource than to wear artificial ears. Artificial ears are made either 
from papier-mache, pressed leather, or cast metal, painted in oil-col- 
ors, and attached to the rudimentary auricles by the aid of a clamp, 
or, when no point of attachment at all exists, by a spring, passing 
over the top of the head, which is hidden by the hair. This, naturally, 
is only applicable to older and controllable children. Otoplastic sur- 
gery, the formation of ears from adjacent integuments, has never, ac- 
cording to Rau^ succeeded in producing a structure at all resembling 
auricles, and hence, on account of the painfulness of the operation, 
and the impossibility of preventing cicatrices, should be abandoned 
entirely. 

Aside from the absence of the auricle, a faulty position of this 
structure is also met with. It either lies very close against the 
cranial bones, auricula adpressa^ or it stands off at a right angle from 
the skull. 

The first deformity rarely calls for any surgical interference, al- 
though the fineness of hearing is somewhat weakened, but in the 
latter we are often applied to for the purpose of improving the ap- 
pearance. In new-bom children very prominent ears may readily be 
brought into a proper permanent position by means of strips of ad- 
hesive plaster which are applied for several weeks. A child was 
once brought to me with one auricle perfectly normal, while the other 
was bent forward or rather deflected to such a degree that its poste- 
rior surface only was seen, completely covering the meatus. 

Even this marked deformity was permanently relieved by the ap- 
plication of strips of adhesive plaster for several weeks. 

(b.) Closure of the Meatus Auditorius, Atresia, sive Ohliteratio, 
sive Imperforatio Meatus Auditorii. — It sometimes certainly hap- 
pens that the osseous canal, in consequence of abnormalities in the 
bones, is entirely absent ; generally, however, it is normally present, 
and its mouth is only closed by a membrane. 

With this condition, a defect or deformity of the auricle becomes 
associated as a complication. 

The aperture of the canal is either indicated by a small depres- 
sion, or the closing membrane is so smoothly expanded over it that 
the bony orifice cannot be detected with certainty either by the touch 



ggQ DISEASES OF CHILDREN. 

or sight. This pseudo-membrane is seldom seen to dip so far inward 
as to represent the canal as a short cul-de-sac. 

This membrane is distinguished from the membrana tjmpani by 
its superficial position, and by its insensibQity when touched with 

*^'^The hearing is almost entirely abolished by this condition; fortu- 
nately, however, the malformation occurs only m one ear. ihis 
membranous closure must also be distinguished from mechanical 
occlusion of the meatus by vernix caseosa, or, in older children, by 
filth and foreign bodies of all kinds. 

The occlusion of the ear often remains undetected for a long time 
when the auricle is well formed, and is discovered by the children 
themselves in the course of years, and as they gain in observation 

Treatment-This defect can only be reheved by an operation. 
This consists in making a crucial incision into the membrane which 
is expanded over the orifice ; the flaps are seized by a fine, hooked 
forceps, and are snipped off with a curved scissors. 

The after-treatment is the most difficult part of the operation, for 
there is always a great tendency to reclosure, which must be over- 
come by the introduction of pledgets of lint, sponge-tents, and sub- 
sequently a silver tube. . 

The meatus, notwithstanding all this, sometimes closes again after 

many months. • i 4. ^v. 

In bony occlusion, which scarcely ever occurs ^vithout other re- 
mote malformations, hemicephaha, etc., notliing of course is to be 
hoped for from an operation. / /^ . • 

(3.) Simple Inflammation of the Meatus Auditorius ( Otitis 
Externa).— ^& omit the inflammations and other alterations of the 
auricle, which, like any other part of the corporeal surface, may be at- 
tacked by various cutaneous diseases, and apply ourselves directly to 
otitis externa, acuta, et chronica. 

Symptoms.— The meatus represents a cul-de-sac, the bottom ot 
which is formed by the membrana tympani. Its anterior part is pro- 
vided with sebaceous glands, its posterior, corresponding to the bony 
canal with ceruminous glands. Although its lining membrane, as far 
as the sebaceous glands extend, is analogous to the external integu- 
ments, still the characters of the membrane lining the osseous canal 
are altogether diS"erent. 

The denomination mucous membrane is not at all appropriate, for, 
in the physiological state, it is arranged for the secretion of the ceru- 
men, which has not the least resemblance to mucus. 

In the inflammatory processes the secretion certainly becomes 
luuco-purulent, and, mth the exception of its smell, is not distinguish- 



DISEASES OF THE NERVOUS SYSTEM. 361 

able from that of an ozoena, and then it may indeed be assumed that 
the membrane so diseased has assumed the properties of a mucous 
membrane. When this metamorphosis takes place, the ceruminous 
glands cease to perform their function ; the reappearance of this cerumen 
may therefore be looked upon as a sign of commencing improvement. 

In the inflammation of the meatus we may distinguish an erythem- 
atous and a catarrhal form. 

In erythematous otitis, the meatus, when closely examined by the 
aid of the speculum, is seen to be reddened, and a brownish cerumen, 
somewhat increased in quantity, is found. After several days, the 
whole meatus desquamates in large or small scales, the large quantity 
of cerumen dries into a crumbling crust, which falls out when the 
patient lies on the affected side, or is washed out by injections. 
This very frequent disease is almost painless ; the auricle may be 
pressed and pulled in every direction, without causing any pain. The 
general state of the system remains undisturbed, and, in children, its 
presence is usually accidentally detected in the examination for other 
diseases. 

Catarrhal otitis produces more significant local and general symp- 
toms than the erythematous. 

The invasion of the disease is attended first by an itching, then by 
actual pains, which, without any other alterations, may last for several 
days, when a yellowish- white, purely fluid or flocculent fluid discharge 
appears. This, at first, is nearly odorless, but at a later date assumes 
an intensely sour odor, or like that of rancid fat. The discharge is 
not always equally profuse, and its quantity is best estimated by the 
stains which are found in the morning on the child's pillow. 

In a profuse otorrhoea, these stains cover the pillow with patches 
the si^e of half of the palm of the hand. After a few days or weeks 
the discharge in the simple otitis externa ceases ; it becomes cheesy, 
and the ceruminous secretion reappears. The deafness that existed 
during the otorrhoea also passes oS. Generally, the secretion poured 
out dries in part in the auricle, and by the irritation it causes produces 
erosions and superficial xilcers, which extend to the lobe and adjacent 
parts, and are much disposed to bleed. At the same time the mem- 
brane lining the meatus swells up to such a degree that the walls al- 
most touch each other, so that the tympanum cannot be seen, not 
even after a thorough cleansing, nor by the aid of the best light. 

The examination with the speculum is exceedingly painful, and 
when attempted produces haemorrhage, which still more obscures the 
parts and counteracts the little benefit that might otherwise be de- 
rived from it, and therefore may be entirely omitted. 

In cachectic, and especially in scrofulous children, otorrhoea easilv 



362 DISEASES OF CHILDREN. 

becomes chronic. It is often absent for months in the warm season 
of the year, and returns in winter with renewed severity. 

Sometimes the secretion is a glairy mucus, sometimes again puru- 
lent, and usually erodes the lobe of the ear. The mucous membrane is 
less infiltrated than in the acute form, but, when the disease has ex- 
isted for a long time, pol^-poid excrescences will form upon it, causing 
a decided aggravation of the deafness. 

A chronic otorrhoea can never be regarded as cured, even when 
the discharge has stopped completely, so long as no cerumen, but a 
cheesy, smeary, fetid mass is found deep in the ear. This is always 
proof that the membrane has not yet assumed its normal function, and 
that the purulent secretion is but temporarily suspended. So long as 
the cerumen is not found in considerable quantities, no complete re- 
covery can be assumed to have taken place. Chronic otorrhoea seldom 
attacks both ears at the same time, and with the same degree of se- 
verity, but an alternating condition usually takes place. 

The prognosis depends upon the state of the membrane lining the 
meatus, and upon the constitution of the child. The degree of the 
svvelhng of the membrane and of the excoriation, the amount of granu- 
lations, the presence of polypoid growths, are all points which enter 
into the prognosis, which must be favorable or otherwise according to 
the degree and extent of these complications. In scrofulous children 
it is likewise very difficult to effect a cure, and the disease returns 
after every exposure to cold and after every indisposition. 

According to Rau and Wilde, the much-dreaded results, perfora- 
tion of the tympanum, secondary periostitis, and diseases of the brain, 
never occur as effects of simple external catarrhal otitis. This view is 
said to have originated from inaccurate diagnosis, which is certainly 
by no means inexcusable, from the fact that, notwithstanding repeated 
injections, the meatus cannot be properly inspected for many weeks, 
particularly if the swelling be at all severe. 

Etiology. — There is an intimate connection, in many children, be- 
tween affections of the mouth and of the ear, as may, in fact, be read- 
ily divined from the anatomical contiguity of the parts. 

Thus there are certain children who, at the cutting of every tooth in 
the first as well as in the second dentition, are attacked by otalgia and 
an otorrhoea, of a longer or shorter duration. This affection occurs as 
a sequela of scarlatina and measles extremely often, and is associated 
with scrofulous eruptions of the head, which extend into the meatus. 
Generally, the otorrhoea in young atrophic infants is not the simple 
external form, but the inflammation extends to the middle ear, and 
will hereafter be described. 

Therapeutics. — Simple external otitis terminates favorably even 



DISEASES OF TEE NERVOUS SYSTEM. 363 

without any treatment, and there is therefore no necessity to torture 
the patient with the vesicants and pustulating ointments so much in 
vogue, by which an additional disease is produced without palliating the 
original one. At first, two or three injections of tepid water, daily, 
and stuffing the ear with charpie, is all that is requisite. If the pain 
is intense, causing sleeplessness, one to four drops of laudanum, ac- 
cording to the age of the child, may be given in the evening. Astrin- 
gent injections in the fiirst days of the discharge are totally useless, and 
in most instances they cause intense pains and an augmentation oi 
the discharge, on account of which it is best to confine the treatment 
for the first eight days to injections of simple warm water. Of all the 
astringents, I consider a solution of alum ( 3 j to water | j) the best 
and simplest, a few drops of which are dropped into the ear morning 
and evening, after the ear has been syringed with warm water and 
wiped dry. This solution is as efficacious an astringent as nitrate of 
silver, and has the important advantage that it neither stains the linen 
nor discolors the skin. After several weeks the discharge ceases entirely. 
If no cerumen appears, a few drops of cod-liver oil with iodine (gr. j to 
I j) should be dropped into the ear. This will cause some itching for 
a time, and will be followed by a return of the normal secretion. In 
scrofulous children, a general treatment with cod-liver oil, iron, baths, 
gynmastics, etc., may always be instituted with advantage, as will be 
more minutely discussed in the chapter on scrofiola. 

(3.) Abscesses in the Meatus ( Otitis Externa Phlegmonosa). — 
The symptoms of phlegmonous otitis, with suppuration, are much more 
violent than those of the previous form. Abscesses can only occur in 
the anterior and easily-accessible parts ; for only this, the cartilagi- 
nous portion, contains a layer of cellular tissue, while, in the osseous, 
the periosteum and lining membrane are intimately united. The pain, 
at first, is bearable, and nothing but a general redness and slight tume- 
faction are observed ; but, after twenty-four to forty-eight hours, the 
pain becomes aggravated to an excruciating intensity ; the child cries 
night and day without ceasing, is unable to sleep, and every motion 
of the lower jaw increases the pain. On this accoiont these patients 
speak indistinctly, and swallow with the utmost caution. Even young 
infants, but a few months old, are liable to be attacked by this affec- 
tion, and indicate to their attendants the site of the disease by fre- 
quently pulling at the ear. After these pains have continued for two or 
three days with uniform severity, they then become throbbing, and can 
only be alleviated by comparatively large doses of morphine. The 
meatus, in the mean time, has become completely closed by swelling, 
and, if examined with a probe, it will be found that the swelling is not 
uniform, but that one part of the meatus, generally the lower, is ele- 



364: DISEASES OF CHILDREN. 

vated into a small fluctuating abscess of the size of a pea. A few 
drops of pus and blood escape when this abscess is opened, or when it 
bursts spontaneously, and the pain then instantly subsides, but the 
little abscess still suppurates for a few days, then becomes completely 
closed, the adja(!ent redness and swelhng also decline, and the whole 
disease in a few days entirely disappears, leaving scarcely a trace be- 
hind. 

I am not aware of any positively certain cause for it. Abscesses 
of the ear occur as well in healthy as in scrofulous children, but are 
especially frequent in children who are teething. The prognosis is 
extremely favorable, a fact that does not always seem probable to the 
less experienced, on account of the violent symptoms which usher in 
the aifection. Induration or ulceration, with exfoliation of the carti- 
lage and bones, scarcely ever ensues. Periostitis of the external meatus 
is very rare in young children ; on the other hand, however, there are 
several diseases following, and frequently due to periostitis of the 
middle ear. 

Therapeutics. — The principal object is the speedy mitigation of the 
extremely torturing pains, which may be accomplished by a cautious 
administration of opium or morphine, they being the most efficient 
remedies. It is also very important that the patients should use a 
firm horse-hair pillow, by means of which the internal ear is less liable 
to be compressed. Topically, it is best to inject warm water, and con- 
duct the steam from hot chamomile-tea upon the abscess. The appli- 
cation of poultices invariably causes pain, and they do not perceptibly 
promote suppuration. The only means by which we can aiford the 
patient immediate relief is to open the abscess as early as possible, 
for vrhich a simple incision suffices. The injections of tepid water 
should then be continued for a few days, when the whole difficulty 
will entirely disappear. 

(4.) IifFLAMMATiOK OF THE MiDDLE Eab [OtUis Interna). — In 
inflammation of the middle ear, either that of the mucous membrane 
alone, or, conjointly with it, of the periosteum and bone, may occur, 
and, for this reason, we have to discriminate between (1) a catarrhus 
and (2) a periostitis auris medire. 

(a.) Catarrhus Auris Mediae. — This disease must be regarded as 
the most frequent cause of the deafness which attends inflammation 
of the ear, and because it usually occurs in both ears at the same time. 
The catarrh is probably propagated from the Eustachian tube to the 
tympanum, and the mucous membrane of the tympanum, when once 
inflamed, behaves like other chronically-afi'ected mucous membranes. 
Hence we see improvement, soon followed by exacerbations. These 
children sufier most from deafness in damp weather, or when afiected 



DISEASES OF THE NERVOUS SYSTEM. 365 

with cold. After hawking, sneezing, or vomiting, tolerably good hear- 
ing suddenly ensues, but, after a few hours, again disappears. 

The diagnosis of catarrh of the tympanum in children cannot be 
as accurately made out as in adults, for the former do not willingly 
submit to have the Eustachian tube explored. Hence the air-douche, 
the chief diagnostic test in the disease, cannot be obtained. The in- 
spection of the external meatus, by the aid of a speculum, furnishes 
negative results, as nothing abnormal can be discovered by it, nor do 
the feeble changes in the color of the tympanum, upon which some 
aurists place great value, supply any sufficient diagnostic information. 
In fact, the principal symptom is a deafness or hardness of hearing, 
changeable with the weather, and combined with catarrh of the mouth 
and nose, and E negative state of the external meatus. 

The termination is usually a sad one, as good hearing seldom re- 
turns in any case of chronic catarrh of the middle ear. The patients, 
therefore, should be content, if the disease do not become more and 
more aggravated, and terminate in total deafness. In most instances, 
the cause is inherited scrofulous cachexia, which, in these children, 
predisposes to hardness of hearing, and is much less liable to become 
localized upon other parts, such as the eyes, nose, and skin. 

Treatment. — The local treatment should be restricted to the ex- 
tirpation of the h^^ertrophied tonsils, abscission of the elongated uvula, 
and inflations of powdered alum into the fauces, because, as has been 
already stated, in children, the catheterism of the Eustachian tube and 
the air-douche can seldom readily be applied. I have treated three 
cases by keeping up a constant pustular eruption alternately behind 
the ears and on different parts of the neck, with very good results. I 
have been led to adopt this treatment from the fact that most of these 
children, suffering from partial deafness, are more or less scrofulous ; 
and I have also repeatedly observed that they are but seldom, and in 
a very slight degree, troubled with cutaneous eruptions, and derive 
benefit from this treatment. Two of the cases above referred to, as 
treated in this manner, recovered their prc^dous good hearing almost 
perfectly, and, although the third is not much improved, still the symp- 
toms exhibit no special aggravations. I am in the habit of employing : 

5. Empltr. adh£Esiv. flav., 3iv, 
Tartar, stibiat. . . . 3j, 

which is smeared upon a piece of linen, of the size of a silver dollar, 
and allowed to lie upon the skin for four days, when the spot will be 
found to be covered with bloody pustules, which are not disposed to 
heal, but will suppurate for many days. As soon, however, as these 
have healed, the same process may be repeated on another place. 



366 DISEASES OF CDILDEEX. 

Tliese children should also be guarded against catarrhs, which is 
best accomplished by inuring them to the changes of the temperature 
by the daily cold bath and country air. A general treatment, with 
iron and cod-liver oil, is also indicated by the scrofulous complication. 

(b.) Inflammation of the Periosteum of the Middle Ear — Peri- 
ostitis — the Real Otitis Interna. — Periostitis of the middle ear is the 
most important and dangerous of all the diseases of the ear, for it not 
only produces the most intense pains, and most frequently leads to 
total deafness, but life is also endangered by purulent meningitis of 
the most intense form, which is apt to supervene. For that reason, 
also, has it attracted the universal attention of aurists, and its symp- 
toms and terminations are much more minutely described than any 
other disease of the ear. 

Symptoms. — In children the disease almost always begins sud- 
denly, and, fortunately, attacks but one ear, never both at the same 
time. A rapidly-increasing, boring, lancinating pain comes on in the 
affected ear, which radiates over the adjacent parts, the temple, back 
of the head, neck, and jaws, and, in a very short time, becomes so in- 
tense as to almost drive the child to distraction. It screams and 
cries incessantly, and cannot be tranquillized in any manner. Toward 
evening the pains reach their utmost intensity ; they are also aggra- 
vated by all movements of the lower jaw, and of the head generally, 
by swallowing, sneezing, cougliing, and particularly by loud noises. 
Nevertheless, the increased irritability of the nerve of hearing, which 
manifests itself by greater sensibility to noise, and by constant buzzing 
in the ears, subsides very soon, and is succeeded by more or less com- 
plete deafness. These violent local symptoms, as might be supposed, 
are not unattended by reflex action upon the general system. Violent 
fever, very frequent and hard pulse, general malaise^ cold sweats, and 
great thirst supervene. 

In nurslings, all the symptoms just enumerated cannot always be 
elicited. They are extremely restless, cry at every noise that is made, 
frequently pull at their ears, and, when at last they have fallen asleep, 
will wake at the slightest noise with a cry of pain, and incessantly 
rub the head to and fro upon the pillow. Pressure upon the affected 
ear also gives rise to the loudest outcries of pain. When put to the 
breast, they will suck at it only for a short time, and break off with a 
cry, because the act of sucking aggravates the pain, and, on the other 
hand, drinks administered by a spoon are swallowed with avidity. 
Like all other pains and febrile diseases, so is also this condition 
capable of causing partial or general convulsions, and then it is very 
liable to be confounded with other cerebral affections. 

The examination of the external ear in the first days of the disease 



DISEASES OF THE NERVOUS SYSTEM. ZQ7 

furnishes no positive results, and, besides, is extremely painful, par- 
ticularlj when the speculum is used. 

These painful phenomena never last longer than five, or at the ut- 
most six days. But, before the expiration of this time, death, in ex- 
ceptional cases, may take place by convulsions, or under meningitic 
phenomena. An actual simple resolution of the inflammation, attended 
by a subsidence of the pains, may indeed also occur, but in this case 
there is always a suspicion of a diagnostic error. In most instances, 
the inflammatory pus and the deposited purulent exudation tunnel 
a passage outwardly in various directions. 

The most frequent termination is by perforation of the tympanum, 
followed by discharge of bloody-streaked, highly-pungent pus. The 
small bones of the ear, and some pieces of necrosed bone, may escape, 
followed finally by the cure of the periostitis, with complete deaf- 
ness of the afi"ected side. Still, it also happens that the small bones 
of the ear are not discharged, that the perforated tympanum, after the 
pus escapes, closes up again, and then a slight hardness of hearing 
only remains. 

Some solitary cases are recorded where the pus escaped through 
the Eustachian tube. They seem, however, to occur but very rarely, 
and cannot be demonstrated in children, who swallow the pus, not un- 
derstanding how to remove it by hawking. 

Another way in which the pus frequently escapes is into the cells 
of the mastoid process. An oedematous redness is then observed be- 
hind the auricle, the red spot bulges up more and more, fluctuates 
distinctly, and ultimately, if left to itself, will open. The copious 
bloody pus which escapes at first likewise has a pungent odor, and car- 
ries ofi" with it some particles of bone, and, after a few weeks, becomes 
mucous and shreddy. If the abscess is explored with a probe, a few 
exposed spots of rough, denuded bone will almost always be detected ; 
sometimes, however, this is impossible, owing to the curved or angu- 
lar course of the cavity. The pus is so rich in sulphuretted hydrogen 
and sulphuret of ammonia, that the silver probe quickly becomes dis- 
colored. Ultimately, the fistulous track closes, but not till after many 
months, and even years, and the contracted cutaneous cicatrix remains 
consolidated with the bones. Deafness is the most usual termination, 
and, in the rarer favorable instances, deafness of a lesser degree simply 
results. When the caries extends to the Fallopian canal, convulsions 
will take place, and subsequently paralysis of the facial nerve, which 
runs through this passage. This paralysis is not permanent in all 
cases ; it may disappear again soon after the pus that has exercised 
the pressure escapes, but, when it has lasted for several months, as a 
rule, it will be permanent. 



368 DISEASES OF CHILDREN. 

I'he worst event to be dreaded here is the involvement of the 
labyrinth, and necrosis of the petrous portion of the temporal bone, 
with consecutive purulent meningitis and encephalitis. The purulent 
collections in the brain usually communicate with those in the internal 
ear, and, when the tympanum becomes perforated, may even escape 
outwardly. But abscesses also occur in the brain without the petrous 
bone being markedly affected, thus proving that otitis interna, aside 
from producing a direct mechanical propagation, is also capable of 
bringing about a concentric cerebritis. These cerebral complications 
invariably terminate fatally. 

Prognostically, the perforation of the tympanum, with discharge 
of the matter outwardly, when the extremely doubtful resolution is 
excluded, may be looked upon as a favorable termination, especially 
if the rare and fortunate event occur of the bones of the internal ear 
being retained, and the tympanum closing up again. 
♦ Much less hopeful and promising is the result in caries of the mas- 
toid process, whereby the deafness usually becomes more marked, the 
fistultB remain open for years, and painful contracting cicatrices form. 
In caries of the petrous portion of the temporal bone, which manifests 
itself by grave meningitic symptoms, by unilateral convulsions, and, 
subsequently, paralysis, the prognosis may generally be regarded as 
fatal. In general, it may be assumed that the children who suffer 
from otitis interna are scrofulous to a high degree, and that, therefore, 
tuberculosis of the lung will, with great probability, ensue after the 
appearance of puberty. 

Etiology. — Scrofulosis and tuberculosis furnish the chief predis- 
posing causes of this affection. It either alternates with scrofulous 
exanthemata, the disease localizing itself, immediately after their rapid 
desiccation, in the internal ear, without any simultaneous external 
otorrhoea, or a similarly scrofulous purulent discharge from the meatus 
auditorius finally causes perforation of the tympanum, and thus gains 
entrance into the middle ear. This affection also supervenes upon an 
acute exanthema, and particularly scarlatina. The exciting causes 
deserving to be mentioned are, foreign bodies in the external ear, 
those that irritate the tjmpanum, such as chemical corrosive liquids, 
which intentionally, with criminal intent, or accidentally, have been 
poured into the ear, and, lastly, violent injuries and blows in the 
region of the ear. 

Treatment. — The extraordinary severity of the pain at the com- 
mencement of the disease induces the relations of the child to covet 
as speedy a relief as possible, which, however, cannot be satisfied in 
most instances as rapidly as is desired. The most effectual of all 
pain-assuaging remedies, opium, ought not to be given to infants, 



DISEASES OF THE NERVOUS SYSTEM. 369 

especially to those wto have not passed the first dentition, because 
sopor, followed by cerebral irritation, may be produced, and thus the 
effects of the opium, and the morbid process which is being propagated 
to the brain, will not be distinguishable. Cautious experiments with 
opium may, it is true, be instituted, even in young children, for these 
dreadful consecutive effects do not ensue in aU cases ; but we have to 
limit ourselves to such small doses, that the desired pain-assuaging 
effects have not usually been realized.* 

Much better effects have been obtained, in young children, from 
bitter-almond water and extract of belladonna. Topical abstraction 
of blood, whose pain-alleviating effects certainly cannot be denied, 
should be very sparingly practised, as almost all children affected by 
this disease are scrofulous, and have already been sufficiently reduced 
by the pain and fever attending it. 

Leeches should never be applied in greater numbers than the num- 
ber of years of the child's age. General abstraction of blood should 
be avoided entirely. 

Most children tolerate nothing in the external meatus nor upon 
the auricle, and the pain is best borne when the ear is entirely free, 
and not in contact with any thing. If, in a few days, the pains become 
throbbing, and the parts in the vicinity of the mastoid process red- 
dened, warm vapors of chamomile-tea may be advantageously con- 
ducted into the meatus, and the parts behind the ear may be poul- 
ticed. As soon as the pus bursts through the tympanum, or exter- 
nally through the mastoid process, all pain suddenly ceases, and it is 
now principally a question of properly keeping up the discharge. For 
this purpose it is absolutely necessary to provide the relatives with a 
good metallic (not glass) syringe, and to instruct them thoroughly in 
its use. Injections of warm water, regularly repeated every two or 
three hours, afford the only guarantee that the matter escapes without 
pain and without interruption. The meatus should never be wiped 
out with the twisted corner of a pocket-handkerchief, for the greatest 
amount of irritation is produced by the practice, and it should be en- 
tirely discarded. But, if it is totally impossible to remove the secre- 
tion, crusts will form, especially on the mastoid process ; the pus is 
then prevented from escaping, and increased pain will be the result. 
In this case, the use of sweet-oil may be of some benefit. If the in- 
flammatory stadium has already expired, astringent injections may be 
commenced, and a solution of alum ( 3 j to water 3 j) will be found 
to answer the purpose best. In caries of the mastoid process, Rau 
recommends a solution of sulphate of copper (gr. ii — xii to water | j) 
to be injected into the cancelli of the bone. 

Internally, during the inflammatory stage, up to the bursting of 

* See also remarks on the use of cocaine, page 584. 



370 DISEASES OF CHILDEEN. 

*;he abscess, small doses of calomel are generally given, by which the 
bowels are kept open, and the intensity of fever diminished. The 
termination in suppuration, however, is not by any means prevented 
by it. The children subsequently require a tonic and anti-scrofulous 
treatment, with cod-liver oil, iron, cinchona, ale, wine, meat diet, sea- 
baths, and country air, etc. 

Referring the student, for descriptions of the rarer forms of inflam- 
mation of the internal ear, and of otalgia and nervous deafness, to the 
special works of Mau, ITra'tner, and Erliardt, we will now proceed 
to make a few remarks upon — 

(5.) Foreign Bodies in the Ear. — There is a great natural pro- 
pensity in the child — proceeding, perhaps, from curiosity — to perform 
various experiments on its body, and to examine more minutely the 
cavities which open upon its surface. Hence the particular dispo- 
sition to push small objects into the apertures, and then to await their 
effects. In most instances the objects pushed into the meatus are 
readily recognized when a ray of sunlight is allowed to fall upon 
them ; but, when tumefaction, as a result of irritation, has already 
supervened, the examination will be much more difficult. Probes 
should only be used with the utmost caution, for with them the extra- 
neous bodies are readily thrust still farther in. 

The symptoms which are induced by a foreign body in the ear 
vary very much according to its nature and form. Smooth, round ob- 
jects, which do not swell up in the ear, often produce no symptoms at 
all for a long time, but, when rough, long, or swollen, the meatus al- 
ways suffers, and painful otorrhoea ensues. The tympanum is liable 
to be perforated by the otorrhoea, and in particular by the unsuccess- 
ful attempts at extraction, and all the symptoms of otitis interna, de- 
scribed in the preceding section, are renewed. The objects most fre- 
quently introduced are : cherry-stones, grape-seeds, peas, beans, len- 
tils, pebbles, glass beads, balls of paper, and pieces of confectionary. 
The lumps of indurated cerumen, cotton, wool, and filth, and con- 
cretions, the so-called otolithes, so frequently met with in aged people, 
are scarcely ever observed in children. Living animalcula, it is true, at 
first produce very unpleasant sensations ; soon, however, they adhere 
to the cerumen, and perish quickly, or may be killed by a few drops 
of water or diluted spirits of wine. The ear- worm (forficula auricula), 
so much dreaded by people, occasions no special danger, but behaves 
in the ear in as harmless a manner as all other Hving animalcula of 
that calibre. 

The most serious symptoms are those occasioned by corrosive sub- 
stances, nitrate of silver, caustic potassa, and the mineral acids, by 
which the tympanum is destroyed in a very short time, and the whole 



DISEASES OF THE NERVOUS SYSTEM. 371 

tram of terrible symptoms of otitis interna is set going. Of all the 
extraneous non-corrosive substances, those of an organic character are 
the worst ; the moisture and warmth of the meatus cause them to 
swell up ; this is especially applicable to peas, beans, and lentils ; in a 
lesser degree also to all fruit-kernels. Small pebbles and glass beads 
are tolerated for a long time without any serious effects, if they have 
not been too firmly wedged in by forcible attempts at extraction. The 
condition is most favorable in confectionary articles ; they soon soften 
and liquefy, a result much accelerated by a few drops of water. 

Treatment. — The only and chief indication, the removal of the 
foreign body, cannot always be quickly enough carried out, for the 
tumefaction of the meatus and pain often render this impossible. 
These symptoms should first be palliated by leeches, cataplasms, drop- 
ping in of oil, and injections with warm water. There are various 
methods of removing the foreign substance, some of which, however, 
are laborious and adventurous. The forcible injection of a stream of 
tepid water is undoubtedly the safest and simplest means of setting it 
afloat. It is hardly ever of precisely the same form as the meatus ; 
the water, therefore, gets behind it, and gradually sets it afloat, and 
it soon after makes its appearance at the verge of the meatus, and 
can thence easily be picked out. If this measure has failed to re- 
move it, we may resort to elevators. These may be made at any 
time, by bending the blunt end of a fine hair-pin toward the flat sur- 
face. The end, thus curved, is carefully insinuated behind the foreign 
body, which is easily brought out. In desperate cases, small blunt 
hooks may also be resorted to ; these should be introduced flat-wise, 
and then turned so as to come against the object from behind. Tlie 
utmost caution, however, should be exercised in their use, for the 
points of the hook may break ofi\, and, if the patient is at all restless, 
the tympanum is liable to be ruptured. Forceps, if the bodies are 
round, such as peas, beans, pebbles, beads, etc., are totally useless and 
even injurious, for two branches require more space than the foreign 
body, in order to embrace it at its largest diameter, and therefore 
rarely grasp it. They almost always slip ofi^, and thereby push the 
article still farther inward. 

A third method, which, to be sure, is very mild, as well as often 
ineffectual, consists in extraction by the aid of some tenacious sub- 
stance which has previously been brought in connection with the ex- 
traneous substance. For this purpose, a quill, cut off smooth at both 
ends, is introduced into the ear, and through this a piece of tape 
soaked in glue pushed down upon the foreign body. After a few hours 
the tape will be found to adhere pretty firmly to the article, and then 
it is sometimes very successfully and agreeably pulled out. But, when 



372 DISEASES OF CHILDREN. 

the pebbles, etc., are firmly wedged, the piece of tape wiii come out 
alone, and the entire procedure will have been a failure. 

All these methods of extraction require the utmost tranquillity 
and steadiness on the part of the patient, which cannot be expected, 
especially from a child. Hence, chloroform will have to be employed 
in most cases, and will be found to immensely facihtate the manipula- 
tions. Otitis and otorrhcea, which result from this accident, must be 
treated according to the principles already prescribed, but they also 
subside, even without any treatment, much more rapidly than the 
cachectic otorrhoea. 



CHAPTER VI. 

DISEASES OF THE GENITO-URINARY ORGANS. 
K.— KIDNEY. 

(1.) Malfoematioj^ of the Kidxets, — The kidneys are never 
totally absent ; even in the most incomplete abortions they may be 
detected in some form. One kidney only is to be found in some 
cases, in which condition Rohitansky makes a distinction between 
the single and the shnple. In the former, a single kidney is found 
at the normal place, to the right or left side of the vertebral column, 
differing in shape but little from the ordinary kidney, while on the 
opposite side there is no trace of a gland. The simple kidney, on 
the other hand, is an abnormal fusion of two kidneys, the most com- 
mon form of which is the horse-shoe kidney {ren unguiformis). In 
this case two separated glands of normal shape are united at the 
lower end by means of a flat bridge of renal substance. The more 
limited this connection becomes, the more distinct the form of the 
simple kidney appears. Finally, also, the two hila fuse together, 
forming a single hilum on the anterior surface. The simple kidney is 
always situated lower in the abdomen than the normal gland, and, as 
a rule, lies in the vicinity of the promontory of the sacrum ; seldom, 
like the single kidney, external to the median line. 

Besides this condition, various other minor deviations in form also 
occur, and in this connection it may be observed that the kidney of 
the new-born child, in the normal state, has a slightly uneven surface, 
and is nearer spherical in form than in the adult, and tapers some- 
what toward the upper end. 

(2.) Uric-Acid Infarctiox of the New-born' {Infarctus He- 
nalis). — ^Uric-acid infarction is a recent discovery, the merit of which 



DISEASES OF THE GENITO-UEINARY ORGANS. 373 

is due mainly to Vernois^ JEJngel, ScJilossherger^ Virchow, Hessling^ 
and Martin^ of Berlin. The infarction manifests itself in sharply- 
defined, golden-yellow streaks in the pyramids. These streaks run 
together concentrically in the papillae, and for that reason are also 
fomad thicker there. Under the microscope they are recognized as 
small cylindrical columns, which, on being strongly compressed, 
crumble down, and a reddish powder appears, consisting of amor- 
phous lithates, epithelium from the straight urinary tubules, and 
small rhomboid crystals of uric acid. When these golden-yellow 
streaks are found in the papillee, some of them will also be seen pre- 
cipitated as a carmine-red powder in the pelvis of the kidney, and in 
the most dependent part of the bladder. 

Urinary infarction is met with in two-thirds of all the children 
who die before the tenth and after the second day of life. It is very 
rarely seen in still-born, and but seldom in children who have respired 
one day. On the other hand, however, it frequently exists longer 
than after the tenth day, and, exceptionally, is even found in children 
who have lived for more than four or even six weeks. 

That this is not a pathological, but a physiological condition, is 
manifest from its frequency, from the absence of all morbid signs dur- 
ing life, and from the fact that the condition is almost invariably 
found in children dying before a certain age from other diseases. 
This phenomenon, according to Virchow, is very easily explained in 
the following manner : Immediately after birth, a more rapid oxida- 
tion of the tissues, in consequence of the processes of respiration, 
takes place, as a result of which, among other products, uric acid is 
formed. This substance, combined with the alkaline bases, is ex- 
creted by the kidneys, but as yet does not find the requisite quantity 
of water in the new-born child to produce its solution. The large quan- 
tities of the excreted urates then accumulate in the straight tubules, 
and appear yellow, for they are combined with the coloring matter 
of the urine. Tlie urine, which subsequently is excreted in larger 
quantities, and is consequently more diluted, partly dissolves it, 
partly washes it onward into the bladder, and thence outwardly. 
A red powder, in fact, is now and then found in the diapers of most 
of the new-bom children, which, on close examination, is seen to 
be uric-acid infarction. This explanation, it is true, is not adapt- 
able to the extremely rare occurrence of lithic-acid infarction in the 
still-born, and therefore it is evident that it is not completely 
exhaustive. Although uric-acid infarction is to be looked upon 
as an undoubted physiological phenomenon, nevertheless it also fur- 
nishes causes for pathological conditions ; for example, it may give 
rise to the frequent passage of gravel, and nuclei for the formation of 
25 



374 DISEASES OF CHILDREN. 

calcxili. In trutli, the germ of calculi in children always consists of 
lithic acid. 

Lithic-acid infarction, regarded from a medico-legal point, is not de- 
void of importance, for it is as positive a proof of life as the dilatation 
of the kmgs by air, and has the additional advantage over this sign 
that it does not become changed so quickly vrith commencing putres- 
cence. Aside from this, it has only an anatomo-pathological interest. 
(3.) Morbus Bkightii (Bright's Disease of the Kidney). — In 
children, Bright's disease occurs in the acute form almost exclusive- 
ly, and only as a sequela of scarlatina. The chronic form is very rare, 
as I infer from the fact that I have met with it only once — that 
single instance presented in a tuberculous boy ten years of age. It 
differs in no respect from the disease as it occurs in adults, and we 
may therefore refer the student to the latest text-books, and particular- 
ly to Frerichs's monograph, a model of exhaustive scientific essaying. 
We confine ourselves to a more detailed consideration of the acute 
form. 

Pathological Anatomy. — The kidneys .usually exhibit those mor- 
bid alterations which Frerichs ascribed to the end of the first or 
commencement of the second stage. They are perceptibly enlarged, 
generally in consequence of an increase in bulk of the cortical sub- 
stance, which is of dark-red color, brittle, and friable. The cut sur- 
faces are very moist, and, on scraping them with a knife, a tenacious, 
bloody serum is obtained. Small extravasations of blood, of the size 
of a pin's head, are also frequently found. The pyramids are much 
less altered, and reveal nothing more than a greater vascular turges- 
cence, which produces a general dark color. 

The enlargement of the kidney is due to an exudation of fibrin, 
which fills up the tubuli contorti, and may be microscopically demon- 
strated in the fluid scraped from the cut surfaces. Numerous Bright's 
casts can be seen under the microscope, which are sometimes clear 
hyaline, sometimes again still surrounded by epithelium-cells, and 
perceptibly contain blood-corpuscles. These casts, though in much 
less quantity, are also met with in the tubuli recti, and are never 
totally absent from the precipitate of albuminous urine. When these 
children succumb at the very commencement of the disease, the urine 
will be found to contain so many blood-corpuscles as to color it dark 
red. After some time, it is clear, yellow, or turbid ; the blood-cor- 
puscles and coloring matter of the blood have disappeared, but albu- 
men and casts may still be detected. At this stage of the case the 
cortical substance exhibits more the character of the second stadium^ 
accordinof to Frerichs's division. 



DISEASES OF THE GENITO-URINARY ORGANS. 375 

It loses its dark color, and at first becomes pale yellow at various 
points, and finally all over. The blood-corpuscles in the plugged-up 
capillaries disintegrate, and are then, together with the coloring mat- 
ter, absorbed, or washed onward; the exudation within the urinary 
tubuli likewise undergoes a retrograde formation, and the casts de- 
generate into fat molecules, and, although they still loosely retain 
their normal form, lose it when pressed by the glass cover under the 
microscope, consequently it is not always practicable to use it in the 
microscopical examinations at this stage. 

The kidney remains increased in bulk, and very brittle, the capsule 
may be pulled oflf with ease, and the upper surface is then seen to be 
slightly granular. This slight unevenness arises from the metamorpho- 
sis of the fat, and the succeeding atrophy, which does not progress 
uniformly on all parts of the cortical substance. While one part is 
already flabby, and begins to waste, the other is firm with exudation, 
and occupies its former large space. 

In acute cases there is only found a very small quantity of urine 
in the bladder; in children who survived for many weeks after the 
attack, it may have returned to its former normal amount. 

Dropsical effusions into the peritoneal sac, pleura, and pericardium, 
die also found in almost all cadavers, often combined with inflam- 
matory exudation, especially upon the pleura. Those morbid altera- 
tions of the rest of the organs, which we constantly observe in the 
chronic form in the adult, do not occur in children. 

Symptoms. — The first signs of disease of the kidney usually appear 
at a time when the desquamation is at its acme, at the end of the third 
week of the scarlatina. The child who, to all appearances, is already 
perfectly well, and has a good appetite, suddenly loses it. It is seized 
with nausea and vomiting, and fever and debility again come on. The 
face, at the same time, assumes a pufifed appearance ; the integument 
of the lower eyelids becomes elevated into glistening sacs, and, in a 
few hours, the entire surface of the body is affected by anasarca. 
Simultaneously with these phenomena, a palpable diminution of the 
secretion of the urine is observed. In the most acute form, the child 
will pass no urine at aU for more than twenty-four hours, and finally 
void a few drops of blood-colored, concentrated lu-ine, the act being 
attended by severe pains. In many cases, however, the urine is not 
very much diminished, nor bloody, but of a pale-yellow tint, or pel- 
lucid, so that, on merely inspecting it, no alteration whatever can 
be detected. There is often also very sharp pain in the lumbar 
region. 

The chemical and microscopical changes of the urine are the same 
as in Bright's disease in the adult. In the first few days the quantitj? 



376 DISEASES OF CHILDREN, 

of albumen, when no great amount of blood is admixed, is less than 
it is subsequently, and varies between ten and thirty pro mille. An 
approximative estimation of the daily loss of albumen may be formed 
by boiling a certain quantity of urine in- a graduated test-tube, and 
allowing the coagulated albumen to settle for twenty-four hours. If 
the total amoimt of the daily discharge of urine is known, then it is 
easy to calculate how many cubic centimetres of albumen are voided 
in the urine. In children, however, the collection of the urine passed 
in the entire twenty-four hours is attended by considerable difficulty, 
and often entirely impossible, for they always discharge the urine 
along with the stools. 

The casts are found with the greatest certainty, and in largest 
quantities, when urine that has been voided some hours previously is 
slowly decanted, and the residue poured into a tall champagne-glass. 
In this glass the urine is again allowed to stand qmetJy for several 
hours, when all but a few drops are poured off, and these last remain- 
ing drops are examined by the microscope. If no casts are found in 
urine thus prepared, it may be safely concluded that none exist. In 
all cases of acute Bright's disease, however, they are seen closely 
pressed together, and lying over each other, and, by examining and 
comparing a large number of these structures, we obtain a true insight 
into the nature of the entire disease. The casts possess different 
qualities, according to the duration of the disease, as already described 
in the pathological anatomy. 

The quantity of urine is generally lessened, the salts are hkewise 
diminished, but the coloring matter in most cases is augmented. In 
the course of the disease, however, the urine again resumes its former 
straw-yellow color. The turbidness and sediments which are fre- 
quently present are partly due to the large quantities of casts, partly 
to the numerous epithelium-cells, and urinary salts. 

Should albuminous urine continue to be discharged for several 
days, the anasarca will increase, and the signs of dropsical effusions 
into the cavities of the body will become superadded. The abdomen 
becomes more and more protuberant ; complete dulness, when per- 
cussed in the sitting posture, is obtained over its lower part, and, in 
the recumbent position, fluctuation is distinctly felt. This, however, may 
arise from oedema of the abdominal parietes. The symptoms of hydro- 
thorax are still more striking. The greater the serous effusion into 
the pleural cavities, the more rapidly and laboriously do the children 
breathe ; the flat percussion-sound gradually rises, and only the rlionchi 
which are propagated through the ribs, and feeble or no respiratory 
murmurs, can be heard. The hydropericardium, which almost simul- 
taneously appears, makes the pulse irregular, flickering, and small ; 



DISEASES OF THE GENITO-DRINARY ORGANS. 377 

the dulness in the praecordial region increases in circumference, but 
cannot be accurately defined on account of the close contiguity of the 
hydrothorax. These children sit upright, hke croup patients, in their . 
little beds, and sleep, if they are able to sleep, with the head thrown 
forward. They grasp firmly at the sides of the bed, in order to fix the 
pectoral muscles, and secure as great a dilatation of the thorax as 
possible, and, with pitiful, beseeching looks, gaze about them in every 
direction for help. 

In progressive increase of the hydrothorax, the patients may perish 
from suffocation ; and, indeed, also oedema of the glottis, or urcemic 
symptoms, as a result of the grave renal disease, may supervene. 
These manifest themselves by headache, loss of vision and hearing, 
and by stupor and deliriimi, and death may also be brought about by 
exhaustion, through persistent vomiting or diarrhcea. 

Hardly ever does a transition into the chronic form of Bright's 
disease occur in scarlatina. The children either die soon under the 
above-described symptoms, or, after two or three weeks, the albumen 
in the urine begins to decrease, the urine is passed in larger quanti- 
ties, the oedema and efiusions into the serous sacs disappear, and this 
is followed by complete recovery. Of this I was once able to con- 
vince myself by the autopsy of the body of a child whom half a 
year previously I had treated for acute Bright's disease, but subse- 
quently lost by a violent typhus fever. The cortical substance of 
the kidney in this case was neither too large nor too small, and micro- 
scopically could in no respect be distinguished from that of the healthy 
kidney. 

All cases of nephritis, which appear with and after scarlatina, do not 
terminate with dropsy, because death ensues too early. Such are the 
cases of scarlet fever which rapidly terminate fatally in vomiting, 
coma, and convulsions, and their unhappy issue is often erroneously 
ascribed to the severity of the fever, to the premature retrogression of 
the exanthema, to hydrocephalus acutus, and, still more conveniently, 
to the intense toxic efi'ects of the contagion. A more accurate inves- 
tigation of the cortical substance of the kidney, in most of these rapidly- 
terminating cases, reveals a marked alteration, like that found in the 
first stage of Bright's disease. 

Conversely, however, cases of oedema of the integument, after 
scarlatina without nephritis, or albuminuria, are also met with. This 
simple anasarca, according to Frerichs, is occasioned by exposure 
to cold during the period of desquamation, and is due to paralysis 
of the vasculo-nervous systems of the integument and subcutaneous 
cellular tissue. 

The most contradictory statements exist concerning the occurrence 



378 DISEASES OF CHILDREN, 

and frequency of nepkritis after scarlatina. While some authors main- 
tain that two-thirds and even three-fourths of all scarlet-fever children 
are affected with it, others, on the contrary, claim that it occurs only 
once in twenty or thii-ty cases. The former hold that it is only neces- 
sary, in all cases, to thoroughly and accurately examine the urine, Avhile 
the latter repel this reproach with indignation, and accuse their op- 
ponents of the grossest exaggeration. But it is possible for both to 
be right, for this depends entirely upon the character of the epidemic, 
and not upon the intensity of the disease. In some epidemics almost 
all scarlet-fever patients become dropsical, in others barely a few. 

Of one hundred scarlet-fever patients, dropsy was observed by 
Haidenhain in eighty per ct. ; by James Miller^ in twenty-seven per 
ct. ; by Wood, of Edinburgh, in twelve and a half per ct. ; by JRosch, 
in ten per ct. ; and by Frerichs, in four per ct. of the cases. 

For a number of years back, scarlet fever has been prevailing 
endemically in ]\Iunich, but is only feebly contagious, and I have 
treated at least betw^een fifty and sixty cases, and but twice only, 
and that temporarily, observed albuminuria. 

Treatment. — In this disease the physician renders the most effec- 
tive service by vigilant prophylaxis. The locality in which the patient 
is confined should be carefully tested for the state of the temperature, 
draught, and dampness, and that room should be preferred which can 
be properly warmed and ventilated, in which no unpleasant draught 
occurs fi'om the opening of doors, and the walls of which are dry. 
Inunctions of fat, on account of the well-known properties they pos- 
sess of rendering the skin less susceptible to changes of temperature, 
are to be employed, even if they do not afford the degree of protec- 
tion w^hich Schneemann ascribes to them. 

This regime is to be continued till the desquamation is entirely 
over, and the child, by a few baths, has again been habituated to 
greater changes of temperature. 

When dropsy and albuminuria have once appeared, the best means 
should be adopted to relieve the stasis in the kidney, by stimulating 
other secretions, such as the skin and bowels. Calomel, castor-oil, 
and senna, subsequently also jalap and colocynth, are preferably 
selected from the class of aperients. The salines are with justice 
avoided, because the salts are in greater part absorbed, and then 
eliminated by the kidneys. In children who are at all predisposed 
to diarrhoea, the utmost possible care must be exercised, otherwise a 
fatal enteritis may be produced. An effort should be made to stim- 
ulate the secretion of the skin — which, in anasarca, is much dimin- 
ished — ^by small doses of tartar, stibiat., or, when the children are 
very restless, by small doses of opium or camj)hor. The main atten- 



DISEASES OF THE GENITO-URINARY ORGANS. 379 

tion is always to be directed to the secretion of the urine. If this is 
properly reestablished, almost all the children, with good care and 
nursing, will recover, but, if it remains suppressed, diuretics should 
be employed to stimulate it. The best diuretic, the only one that is 
unattended by any unpleasant conseciitive effects, and which can be 
given for a long time without disturbing the digestion, is roob juni- 
peri, as fresh as possible. Children take it most readily when it is 
sweetened and diluted with a little water. Its dose is two or three 
teaspoonfuls in the twenty-four hours. I have repeatedly con- 
vinced myself of the good effects of this remedy, and in children 
prefer it to digitalis, bitartrate or acetate of potassa. 

[Jaborandi, or its alkaloid pilocarpine, hypodermically, is now 
frequently used for the purpose of producing diaphoresis. Care, 
however, is necessary in using this remedy on account of its de- 
pressing action in cardiac disease with dilatations. I have found 
dry cups, applied for several days in succession over the region of 
the kidney, to surpass all other remedies in removing the inflamma- 
tory products in the kidney, and thus restoring it to its proper func- 
tions. The hot bath is another excellent remedy in this disease ; 
most children, however, dread it very much, and struggle against 
being put into it, to such a degree as to make its use impossible.] 

Threatening uraemia must be relieved by vegetable acids and alka- 
line baths. For profuse diarrhoea, plumbi acetas, daily two or three 
grains combined with opium, has proved to be most effectual. In 
case the oedema and albuminuria should not have disappeared in 
three or four weeks, as it generally does, a tonic treatment with tan- 
nin, cinchona, and the preparations of iron, is then indicated. For 
the remaining ansemia, the administration of wholesome, easily 
digestible food, and the enjoyment of fresh country air, will answer 
the purpose satisfactorily. 

(4.) Renal Calculi, Renal Tubercles, Renal Cysts. — Al- 
though concretions in the uropoetic system of children are of fre- 
quent occurrence, and have their foundation in the physiological 
lithic-aeid infarction already described, still stones of larger dimen- 
sions very rarely form, at least such as would give rise to more 
decided symptoms. In these cases there are very generally present 
severe renal pains, a purulent sediment in the urine, and the passing 
of small concretions, attended by violent jDains in the course of the 
ureters and urethra. The pus in the urine is due to secondary in- 
flammation of the pelvis of the kidney, and of the irritated mucous 
membrane of the ureters and of the bladder. 

The treatment consists essentially in allowing the children to 
drink as much water as possible, for thereby the existing concre- 



380 DISEASES OF CHILDREN. 

tions, on the one hand, are more readily washed along, and, on the 
other, diluted urine must tend to diminish the gravel rather than to 
promote its deposits. When large ulcerations have formed in the 
pelvis of the kidney, fever will supervene, which quickly assumes a 
hectic character, and is soon followed by death ; or the affected 
kidney may totally disappear, leaving the opposite one to perform 
a double duty. 

Renal tubercle occurs in two forms. In one case the kidney is 
simultaneously attacked with the rest of the parenchymatous organs, 
by miliary tuberculosis, which scarcely produces any renal symptoms 
at all, and is only discovered in the cadaver. In the other, the tuber- 
culosis in boys is more of a local nature, and extends upward from 
a tuberculous testicle, first to the mucous membrane of the bladder, 
and then to that of the ureters, and finally also to the kidneys. In 
this case a considerable portion of the kidney may be encroached 
upon by a large, yellow, cheesy tubercle, and become excessively hy- 
pertrophied, the upper surface thereby assuming an uneven, nodular 
appearance. Suppuration, and degeneration even, occurs in the yel- 
low tubercle, by which finally the tuberculous renal cavities, and ulti- 
mately phthisis of the kidney, are produced. The treatment of renal 
tuberculosis is very hopeless, and must be confined entirely to the 
improving of the constitution by tonics and cod-liver oil. 

Cystic formations are very common in the kidneys, and are even 
met with as congenital conditions. Obstetric cases are recorded in 
which the abdomen had become so distended by foetal cystic forma- 
tions in both kidneys, that it presented an impediment in the delivery. 
Simple cysts, of the size of a hemp-seed up to that of a cherry, are 
very frequently found in the most varying autopsies. They are al- 
ways situated very superficially in the cortical substance, and most 
of them are filled with a clear, pellucid, thin serum. The chemical 
investigation of this serum reveals the presence of a slight amount of 
albumen, and only exceptionally of those chemical substances which 
characterize the urine, such as urates and lithic acid. It is generally 
assumed that they are caused by an occlusion of some urinary tubules 
by uric-acid infarction, subsequently also by calcareous concretions, 
extravasations, and exudative casts. The acephalo-cystic sac and the 
composite cystoides are extraordinarily rare in the kidneys of chil- 
dren, and their consideration may therefore very properly be omitted. 

^.—BLADDER. 

(1.) Malformation. — (a.) Total absence of the bladder \% 2in ex- 
tremely rare occurrence, and is always combined with malformations 



DISEASES OF THE GENITO-URINARY ORGANS. 381 

of other organs. The ureters terminate in the navel, the rectum, or 
vagina. The following condition is more frequently observed : 

(b.) Fissure of the Bladder, Prolapsus, s. JExtroversio, s. Defectxis, 
s. Ectopia, Inversio Vesicm Urinarim. We understand by all these 
denominations a defect of the anterior wall of the bladder, and of 
the corresponding portion of the abdominal parietes, so that the 
posterior wall of the bladder lies freely exposed (PI. III., Fig. 10). 

Two forms, a total and a partial, are distinguished. In the first 
the abdominal fissure extends from the navel to the pubis and genitals. 
In the second, a well-formed navel, normal genitals, and only a small 
opening in the anterior abdominal parietes, exist. A highly-red 
chasm, of the size of a silver dollar or more, is found in the new-born 
child in the region of the bladder, which is bounded by a sharp cutane- 
ous ring. This red gap is only filled up after birth by the posterior 
wall of the bladder becoming invaginated in it through the action of 
the abdominal pressure during crying and defecation, appearing as a 
fleshy, soft, fluctuating tumor. This tumor is constantly moist and 
tenacious, and presents at each side, in its lower part, two small eleva- 
tions, which correspond to the place where the two ureters terminate, 
and are most distinctly recognized when the tumor is displaced a little 
upward. On closer examination the urine will be seen to ooze out in 
drops from these points, emitting its characteristic ammoniacal odor. 

After several years, the cutaneous ring, by increasing granula- 
tions, grows somewhat over the prolapsus, and thus diminishes the 
exposed surface of the mucous membrane of the bladder ; but a 
large portion of its posterior wall nevertheless remains uncovered. 
After a while the exposed portion loses the character of mucous 
membrane, and that portion above the ureters becomes dry, callous, 
and insensible ; below them the prolapsus frequently becomes exco- 
riated, in consequence of the incessant flow of the ammoniacal urine 
over it, and acquires a fungous appearance. 

Complete fissure of the bladder always extends into the genitals. 
The penis is very short, close to the prolapsed bladder, and either 
totally or partially split. In the latter case, it has the appearance as 
if split from the urethra upward, so that the urethra is not a closed 
canal, but represents a trough, fissured on its upper surface. In ex- 
tensive fissures, an oblong appendix, which is the split penis, hangs 
on both sides, and the line of division extends into the scrotum, on 
account of which it may be difficult to discriminate the sex. This 
discrimination becomes still more difficult when, as is usually the 
case, the testes still remain in the abdominal cavity. 

Analogous splittings occur in the female sex. The clitoris is 
divided, the labia majora and minora cloven, and the vagina is often 



382 DISEASES OF CHILDREN. 

totally absent. The peringeum is extremely short, and the anus is 
situated directly behind the genitals. It may even be advanced so 
far anteriorly that it terminates in the posterior wall of the bladder, 
and the feculent matter may likewise be evacuated by the prolapsed 
bladder. 

When the fissures are thus extensive, the rami of the pubis will 
be found developed in a rudimentary form only. They either simply 
terminate in the vicinity of the prolapsus, or are united to each other 
behind it by a narrow band. The pelvis is very wide in its transverse 
diameter, but narrow antero-posteriorly. The sacrum and coccyx 
are very much curved forward, to which are due the shortness of 
the perinaeum and the termination of the rectum far anteriorly. 

The effects of this deformity vary according to its extent. In all 
instances the patients afflicted with it generate a disgusting urinary 
odor, and suffer from constant excoriations around the openings of 
the ureters. In fissures of the penis, the highest degree of epispadia, 
or in imperfect development of the vagina, the individuals are natu- 
rally incapable of propagating the species. There is nothing in these 
deformities incompatible with life, and cases are known where the 
persons attained to an age of even forty years. Indeed, Huxham 
describes the very remarkable case of a woman who, afflicted with 
this prolapsus vesicas congenitus and cloacae, married in her twenty- 
third year, conceived, and gave birth to children. The husband of 
such a creature deserves almost as much admiration as herself. 

Numerous hypotheses have been advanced in regard to the origin 
of ectopia of the bladder. The explanation given by J. 3Iuller 
seems to be the most plausible. According to this author, the blad- 
der is not formed through the reflection of a lamina, but merely by 
the gradual dilatation of the pouch, which, with the urachus, is 
pinched off from the sinus urogenitalis. But the urachus does not 
originate through the reflection of a lamina, but is only the neck of 
the allantois, which primarily grew forward from the intestinal 
canal like a small vesicle. From these two facts J. Mailer infers 
that we have not here to deal with an an-est of development, nor 
with a stopping of the bladder at a former stage of development, 
but he is rather of the opinion that the absence of the anterior wall of 
the bladder is due to a rupture of the sac which occurred at a time 
when the abdominal parietes were not yet completely formed. This 
rupture must have its foundation in a transient or permanent im- 
permeability of the urethra, by which the urine that is accumulating 
in the bladder distends it to such an extent that it finally bursts. 
In this manner there originates an opening between the navel and 



DISEASES OF THE GENITO-URINARY ORGANS. 383 

the external genitals. The simplest form of this malformation is 
epispadia, escape of urine on the upper surface of the penis or above 
the pubes, but the ordinary effect is a large opening between the 
umbilicus and pubic bones. 

Treatment. — An operation, having for its object the closing of the 
defect by freshening the edges, and uniting them by the aid of 
needles or sutures, is to be entertained only when a permeable ure- 
thra exists ; but, even where this condition obtains, a very rare one, 
the hopes of the operation, so far as I know, are invariably disap- 
pointed by the irritating effects of the urine, which constantly bathes 
the raw surfaces of the wound. Our efforts consequently are lim- 
ited to the preventing and healing of excoriations, by securing the 
utmost possible cleanliness, and by pencilling the exposed surface 
with pure oil. When the child gi'ows up, an attempt may be made 
by JEarVs apparatus to lessen the disgusting odor. It consists of a 
hollow silver shield provided with a caoutchouc tube with a stop- 
cock, and is secured to the prolapsed bladder by a double truss. 

c. Cloacce. — Communications between the rectum and bladder 
have already been spoken of, in connection with malformations of 
the recturci. 

(2.) Cataerh of the Bladder, iNFLAMMATioisr of the Blad- 
der (Cystitis). — This is a rare disease in childhood. It occurs as a 
result only of external injuries, or rough calculi, or from the misuse 
of cantharidis, and at the close of grave diseases, such as typhus 
fever, cholera, and small-pox. 

Pathological Anatomy. — These causes hardly ever produce more 
than cystitis mucosa, or catarrh of the mucous membrane. External 
injuries may, in very rare instances, occasion cystitis serosa, or inflam- 
»mation of the serous coat of the bladder ; or pericystitis, an inflam- 
mation of the connective tissue which loosely surrounds the bladder. 

The inflamed mucous membrane is deeply injected, and, when the 
disease has existed for some time, will have a grayish-brown tint, 
will be thickened, and large quantities of mucus found at the bot- 
tom of the bladder ; even excoriations of the mucous membrane and 
diverticulae are occasionally observed. The most extensive morbid 
lesions are always seen when calculi having rough surfaces exist. 

Symptoms. — In some cases the vesical symptoms may develop 
themselves very rapidly ; for example, in children who are suscepti- 
ble to cantharidis they may come on within twelve hours after the 
application of a blister. In calculi, on the contrary, they come on 
very insidiously, often improve, and then relapse. 

Pain and tenderness in the region of the bladder, rectum, and 
urethra, constant dysuria, voiding of a dark, turbid, and even 



384 DISEASES OF CHILDREX. 

bloody urine by drops, are the constant symptoms. In the severest 
grades of the disease — which, however, are never met with in chil- 
dren — there are also observed distention of the bladder, complete 
ischuria, fever, typhous and peritonitic symptoms, sopor, green 
vomiting, collapse, cold sweats, etc. 

The urine always contains a large quantity of vesical epithelium, 
mucus, and pus, and, when first passed, it has a wheyish turbidity, but 
does not clear up completely, even when allowed to stand for a very 
long time, and precipitates a thick, tenacious sediment. It rapidly 
decomposes, generates ammonia, and produces a brownish stain even 
on silver instruments. In diphtheritic cystitis, only observed in 
badly-ventilated hospitals, and which is complicated with diphthe- 
ritis of other mucous membranes, large pieces of false membrane 
are also voided with the urine, attended by the most excruciating 
strangury. 

The course of cystitis varies very much according to the cause. 
That form produced by cantharidis passes off most quickly and 
surely. The urine becomes perfectly clear again in a few hours, is 
voided without any pains, and the symptoms disappear without 
leaving a vestige behind. Cystitis at the end of grave diseases lasts 
longer ; still, even in this case, when the general recuperative pro- 
cess is active, it terminates after a few weeks in recovery. The 
prognosis of traumatic cystitis depends upon the severity of the in- 
jury, but, in making it, it is well to bear in mind that, by virtue of 
the greater reproductive powers in childhood, more extensive inju- 
ries may be recovered from, and greater deformities remedied in a 
given time, than in adults. 

The case is much worse in cystitis, caused and kept up by a cal- 
culus. Even here, it exceptionally happens that the catarrh, not-, 
withstanding the existence of the stone, disappears, a result only 
probable when the stone is very smooth. Usually, however, the 
inflammatory symptoms last as long as it remains in the bladder, 
disappearing totally after it has been removed. Children affected 
with calculi and catarrh of the bladder do badly, both mentally and 
bodily ; and lithotomy, if the diagnosis is sufficiently clearly estab- 
lished, cannot be too quickly practised, especially since this opera- 
tion in children is incomparably easier to perform, and less danger- 
ous, than in adults. 

Treatment. — The removal of the cause is the most essential part 
of the treatment. Should a cantharidal vesicant be upon any part 
of the body, it should be removed instantly. It not very infre- 
quently happens that mild vesicants remain for several days upon 
the skin without producing any topical inconvenience, and then 



DISEASES OF THE GENITO-URINARY ORGANS. 385 

suddenly vesical pains come on, and the ignorant relatives have not 
the least idea of the intimate connection between the worthless old 
plaster and the violent harassing symptoms. 

The patients should be ordered to drink as much as possible of 
almond-milk and emulsions of flax-seed, so as to dilute the urine ; 
and to partake of bland food, such as milk and broths, containing 
as little salt as possible. The quantity of urine in the bladder 
should be carefully controlled, and the hypogastric region often 
percussed. The catheter should be introduced as soon as any dul- 
ness is perceptible, and the urine drawn off. The instrument, how- 
ever, should never be left in the urethra, for the access of air de- 
cidedly aggravates the inflammation. 

Thorough evacuation of the bowels should be obtained, but 
saline aperients must be avoided. Several calomel powders, of a 
few grains each, render the best service. For the strangury, moist 
warm cloths, laid upon the hypogastric region, have proved to be 
very effectual ; in sleeplessness, some preparation of opium and bit- 
ter-almond water may be prescribed. In chronic cystitis, several 
grains of tannin may be given daily, or injected into the bladder. 
Patients with calculus should be operated on under all circumstances. 

(3.) Enuresis, Incontinentia Urinje, Mictio Involuntaeia. 
(The nocturnal micturition in bed.) — Constant dribbling, or an en- 
tirely involuntary passage of urine, often occurs in children, and 
continues till they are several years old ; but it is seen only in cases 
where marked cerebral affections are present, such as idiotism and 
chronic hydrocephalus. This condition is due to an actual paralysis 
of the bladder, of which the muscular coat, as well as neck, is in- 
volved, thus permitting the continual escape of the urine, though 
the bladder may contain but a moderate amount. This condition 
continues incessantly by day and by night, and should be distin- 
guished from the nightly micturition in children otherwise well- 
developed. The latter occurs much more frequently in boys than 
in girls, and in most instances lasts up to the twelfth year of life — 
in exceptional cases, even till the appearance of puberty. It by no 
means depends upon great local or cerebral lesions, otherwise it 
would not regularly terminate in recovery, and would also persist 
during the day. In this instance an inferior degree of sensibility 
of the bladder to the irritation of the urine must exist, as a result 
of which it does not indicate its condition during sleep, or the sleep 
must be so profound that the ordinary irritation of the urine upon 
the filled bladder does not rouse the child. The latter view seems 
to be sustained by the circumstance that many children affirm that 
they had distinct dreams of sitting upon the chamber and passing 



386 DISEASES OF CHILDREN. 

tbeir water in the customary manner. They generally pass their 
urine in bed but once during the night, during the first few hours 
of sleep. I cannot see that slothfulness, b'ad habits, or negligence, 
satisfactorily explain the causes of enuresis nocturna. In most of 
the cases which I have observed, the children, through their own 
sense of honor, or on account of repeated punishments, had a lively 
interest in avoiding the accident, and yet were unable to do this 
without appropriate treatment pursued for months and even years. 
I am likewise unable to confirm the opinion of some authors, that 
chemical alterations of the urine may be the cause, for chemical 
investigations of the urine, instituted in three cases of enuresis, 
taught me that the urine does not in any manner vary from its nor- 
mal quantitative nor qualitative composition. On the other hand, 
however, the statement, that most of the children suffering from 
this misfortune are not particularly blessed with perfect health, is 
correct, for they usually labor under scrofulous affections of the 
most varying kind, or under rachitis or helminthia. 

The effects of this malady are rather unpleasant, for the psychi- 
cal development in particular suffers. The repeated punishments 
which these children undergo blunt their sense of honor consider- 
ably ; they become cowardly and deceitful, and have no personal 
spirit. If great and expensive cleanliness is not practised, the bed, 
and even the whole room, acquires a urinous odor, which contami- 
nates the atmosphere and begets conditions which are by no means 
favorable to the metamorphosis of the tissues. Such children may 
be ultimately attacked by indolent ulcers on the nates and lower 
extremities, the results of the urinous excoriations. 

Treatment. — A treatment directed to the removal of the cause 
may become necessary, when marked symptoms of intestinal worms, 
of scrofula, or nervous hyperaesthesia, become manifest, which must 
be met with anthelmintics, cod-liver oil, iron, cinchona, and aromatic 
baths. Lallemand praises the latter, in particular, very highly. He 
allows four or five handfuls of some aromatic species of herbs to 
stew in a covered vessel, and this decoction, together with a glassful 
of brandy, to be poured into the bath, which is covered by a cloth, 
so that the head of the child only is exposed. In this bath the child 
is to remain from one-quarter to half an hour, and after several 
baths the quantity of the herbs and of the brandy may be doubled. 
These baths must be repeated daily or every other day for several 
weeks, whereupon a recovery ensues. 

The dietetic treatment consists in first taking the precaution 
that the child eats or drinks nothing for several hours before retir- 
ing for the night, by which the secretion of urine is reduced to a 



DISEASES OF THE GENITO-URINARY ORGANS. 337 

minimum ; and, although it may pass off involuntarily during the 
night, still the quantity will be very small. It is also advisable to 
make the patients sleep in the lateral posture, because it has been 
repeatedly observed that they invariably pass their water while 
lying upon the back, but remain clean when they sleep on the side. 
In order to prevent them from rolling over on the back in sleep, it 
is suggested that a cloth or sheet be tied around the body with a 
large knot fixed exactly over the spinal column. The pain which 
it causes, when they attempt, to roll over on the back, instantly 
rouses them. 

This advice sounds very simple and plausible, but always fails 
in • its purpose, because children will not tolerate a band around 
the body so tight that it would not become displaced through the 
night. They urinate in bed as much as ever, notwithstanding the 
knot, and, when they are raised up, it is found shoved over to one 
side. 

There is no necessity for the physician to advise any psychical 
or corporeal chastisement. Usually these remedies have already 
been fruitlessly employed, on the most extensive scale, before he 
was consulted. Still less are terrifying measures, such as the men- 
ace of applying a red-hot iron, suggested by Boerhaave and Caspar, 
to be permitted, or recommended, for a very injurious effect may 
thereby be produced upon the nervous system. 

Of the internal remedies, two are especially efficacious, namely 
belladonna and nux vomica. Of the former, one-twelfth to one- 
sixth of the extract may be given every evening, the dose being 
increased till the pupils become dilated. By this treatment, the 
enuresis is arrested for several days, but it usually relapses ; yet it 
is not advisable to continue it for a long time with large doses. In 
many cases I have derived a much more durable effect from strych- 
nine nitric. This preparation is preferable to the ext. nucis vomicse 
spirit., for the quantity of strychnine in the latter is by no means 
always uniform, and the gradual increasing of the dose is, there- 
fore, more apt to be attended by symptoms of poisoning. It is best 
to give it in powder, simply triturated with a little sugar. Children 
over three years of age are at first allowed one-thirty-second, then 
one-twenty-fourth, etc., up to one-eighth of a grain ; strong coffee 
should be prepared and always kept ready at hand in case symp- 
toms of poisoning come on, such as twitching of the muscles, etc., 
which are most certainly controlled by it. With this treatment, 
the object aimed at is usually attained in from eight to fourteen 
days, and generally the cure is also permanent. 



388 DISEASES OF CHILDREN. 

The experiment which readily suggests itself, to tie the penis with 
a piece of tape, and thus prevent the escape of the urine in a purely 
mechanical manner, is impracticable, for it causes oedema of the penis 
and erections. A case has occurred where a boy, from fear of the 
brutal chastisement which he was promised if he wet the bed, tied 
his penis so tight that he was unable to loosen the knot on the next 
morning, and the result was partial gangrene and a urethral fistula. 

[In an article on the treatment of incontinence of urine in child- 
hood and youth. Sir D. J. Corrigan, Bart. {Dublin Quarterly Jour- 
nal of the Medical Sciences, February, 1879), describes the result 
of a successful mechanical treatment by collodion. While the pre- 
puce, slightly curved up, is held with the left hand, collodion is 
smeared over the little cup thus formed by the extremity of the 
prepuce, by means of a camel's-hair brush, or other blunt instru- 
ment ; the collodion, instantly solidifying, draws closely together 
the edges of the prepuce, and closes the exit for the escaping urine. 
A fortnight's use of it every night, carefully and diligently, is some- 
times sufficient for the cure. When it is desired to pass urine, the 
little wedge or cap of collodion is easily removed by the finger-nail. 
Contrary to w4iat might be expected, the patient is not compelled 
to rise at night to urinate ; on rising in the morning the prepuce is 
found slightly distended wdth urine. From this Dr. Corrigan in- 
fers that the escape of the urine is rather due to the want of appo- 
sition in the sides of the canal of the urethra, or to a feeble state of 
the circular fibres, which are supposed to constrict the sphincter of 
the neck of the bladder. 

The bed should be raised at the bottom so as to form an inclined 
plane from the hips to the feet, so as to allow the urine in the blad- 
der to gravitate toward the fundus, rather than toward the trigone. 
Dr. Corrigan objects to the usual practice sanctioned by the recom- 
mendatioQ of some medical authorities, that the child should be 
awakened at stated intervals to pass his urine ; believing that the 
bladder is thus trained to empty itself at stated periods, instead of 
being accustomed to retain its contents.] 

(4.) Ischuria. Retextiox of Urine. — Retention of urine in 
adults and children is a symptom of the most varying kinds of 
morbid conditions. Hence we have ischuria paralytica, spastica, 
inflammatoria, organica, and mechanica. Of all these kinds, but 
a single one, ischuria spastica, occurs in children. Nervous chil- 
dren, who suffer much from flatulence and colic, will sometimes 
pass no water for more than twelve hours, on account of which 
their attendants are thrown into the greatest anxiety. The pa- 
tients become very restless, cry fearfully, draw up their lower ex- 



DISEASES OF THE GENITOURINARY ORGANS. 389 

tremities against the abdomen, take the breast but little, and con- 
sume a small amount of fluid, but this enables them to pass a 
long time without urinating. It is not a very serious accident or 
disease, and I have never yet met with a case where actual mechan- 
ical impediments had to be overcome. The only point which may 
be interesting is that, in infants a few weeks old, the passage of 
lithic-acid infarction, in the shape of small, red, sharply-angular 
grains, may occur. 

The treatment is extremely simple, for the introduction of a 
shghtly-curved, well-oiled probe will always produce a discharge of 
urine immediately. To prevent recurrence of the vesical spasms, 
the appHcation of a bag of chamomile-flowers upon the hypogastric 
region is very useful. It is, in fact, much more so in children than in 
adults. 

(5.) Yesical Calculi, Calculijs Vesica. Lithiasis {^I'^laciqy 
— Calculary affections are comparatively frequent in boys. Nearly 
forty per cent, of all the individuals operated on for Hthotomy are 
children under ten years of age, as is seen from the statistical state- 
ments of Prout^ who reported 1,356 cases of lithotomy operated on in 
the large hospitals of Bristol, Leeds, and Norwich. The reason for 
this singular circumstance is found (1), in the physiological uric-acid 
infarction, a few granules of which may readily remain lying in the 
bladder, and thus form the nucleus of the stone; and (2), in the quan- 
tity of the phosphates which occurs in the urine of rachitic children. 
In rachitis the urine becomes so rich in phosphoric acid and carbonate 
of lime, that a decided stratum of white powder remains after the 
evaporation of the urine which these children leave on the floor, a fact 
to which my attention was once called by an observing nurse. 

All kinds of vesical calculi occur in children — the urate, oxalate, 
and phosphate. The lithic-acid calculi, consisting of this acid and 
its salts, are moderately hard, smooth, and most of them are yellow- 
ish brown in color, because the coloring matter of the tirine is almost 
always precipitated simultaneously with the lithic-acid sediment, and, 
as a rule, forms the nucleus of the stone, although the external 
layers have a different chemical composition. Most of the calculi 
composed of phosphate of lime and triple phosphates are soft, light- 
colored, of light gravity, and rough on the outer surface. Oxalic- 
acid calculi, which in children form but very rarely, are the hardest 
of all, brown in color, and of a rough, nodular surface, on account 
of which they have also been called mulberry calcuh. Calculi com- 
posed of cystin and those of carbonate of lime are extremely rare. 
The first-named calculi may also combine with each other, when the 
26 



390 DISEASES OF CHILDREN. 

nucleus will usually be found to consist of lithic acid and tlie outer 
strata of phosphates. 

There is generally but one stone in the bladder ; when several 
occur they grind themselves smooth against each other. Smooth calculi 
are very movable, while the rough and thorny calculi remain lying 
at some place at the base of the bladder, and become united with 
the mucous membrane. The effects of a stone vary according to the 
circumstances. There are patients with calculi who have not the 
least traces of catarrh of the bladder, and experience scarcely any 
difficulties ; in others, again, the voiding of the turbid, flocculent 
urine is attended by the most excruciating pains, radiating from the 
neck of the catarrhal bladder over the rectum, penis, and thighs. 

Symptoms. — The utmost care and skill are sometimes requisite to 
diagnosticate a stone with certainty. A correct diagnosis is of the 
utmost importance, because it determines the question for or against 
a dangerous operation. The most rehable signs, according to Pltha^ 
are: 

(1.) The objective — the sensation of a heavy movable body in the 
bladder, which alters its position according to the attitude of the body 
— a symptom rarely observed in children. 

(2.) Pains in the neck of the bladder on standing, walking, sitting, 
and defecating, but which disappear by lying quietly for some time. 
Active exercise, such as running, riding in a wagon or on horseback, 
renders this pain intense beyond endurance, and the existing catarrh 
of the bladder then undergoes a marked aggravation, and finally bloody 
urine may be voided. 

(3.) These pains are often referred to the apex of the glans penis, 
and along the course of the urethra, causing the child to hold the 
penis constantly in the hand, and thus lead to masturbation. This 
habit produces a remarkable enlargement of the penis and elongated 
prepuce. 

(4.) Pain and difficulty in micturition. The pains become most 
intense toward the termination of the act, and last for a long time 
afterward. Occasionally the stream of urine is suddenly arrested and 
does not start again until the child has lain down or assumed a differ- 
ent position. The child accurately describes the sensation of a foreign 
body having suddenly interposed itself, and is able to displace it by 
changing its attitude. 

(5.) The most important sign is always derived from the examina- 
tion with the sound. An audible clang produced by the steel sound 
in the bladder cannot be due to any thing else than a vesical calculus. 
Moreover, by lightly touching the stone, and by the more or less clear 
tone thus produced, even an approximative idea of its hardness, smooth- 



DISEASES OF THE GENITO-URINARY OEGANS. 391 

ness, and mobility, may be obtained. The smaller the calculus the 
more difficult, of course, it is to find it. It is sometimes necessary to 
examine the patients in different positions, standing-, lying on one side 
or on the other, or on the back, taking care that the bladder be filled 
or partly filled with urine. In some instances it may be felt by in 
troducing the finger into the rectum. The exploration with the sound 
in children is seldom successful, and incomplete or impracticable with- 
out the aid of chloroform. 

The course of the disease is almost ahvays the same. It happens 
only rarely that stones larger than peas pass off by the urethra, and 
still more seldom that they are evacuated through the vagina, rectum, 
or perineeum, as a result of ulceration. 

If no artificial aid is rendered them, the jDatients will retain their 
calculi to the end of life, which, although attended by constant torture, 
may be protracted for many years. Ultimately they become atrophic, 
have hectic fever, loss of appetite, exhaustion, and sleeplessness, and 
perish miserably, or urasmic symptoms and nephritis become super- 
added, and these are speedily followed by death. 

Treatment. — There is only one indication, and that is, the removal 
of the cause of the disease, the foreign body from the bladder. This 
has already been tried by the most varying internal remedies, the so- 
called lithotriptica, and by direct injections into the bladder. The 
effect, however, of these calculary solvents is still extremely proble- 
matical. The waters of various springs are recommended, especially . 
Vichy, Kxeuznach, Eger, and Franzenbad. Of the internal remedies 
may be mentioned the alkaline carbonates, phosphate of ammonia, 
herba uv£e ursi, electro-magnetism, and weak injections of fluids, which 
concentrated are certainly capable of dissolving the stone, but in this 
state cannot, of course, be introduced into the bladder. 

The mechanical removal of the stone through the urethra succeeds 
only in very few instances in the female. The male urethra, on ac- 
count of its narrowness and length, is unadapted to this method of 
practice. 

We have, therefore, no other resource but its removal by a surgi- 
cal operation, by lithotomy or lithotripsy. The description of these 
two methods of operation belongs to the study of surgery, and is found 
magnificently delineated in Pitha's Diseases of the Male Sexual Or- 
gans, Virchoio's Pathology and Therapeutics. 

In regard to the choice of the operation, whether lithotomy or 
lithotripsy should be preferred, it is only necessary to state here that 
lithotomy is even better adapted to children than to adults. Accord- 
ing to the declarations of all experienced surgeons, children furnish 
an extraordinarily favorable ratio of recovery. The calculi are seldom 



392 DISEASES OF CHILDREN. 

very large, the reaction is mostly slight, and recovery speedily follows 
in almost all cases, while lithotripsy has to battle especially with the 
narrowness of the youthful urethra, on account of which also chloro- 
form has to be administered at every sitting, and the consecutive 
pains at the passage of the fragments are very severe. 

Q.—MALE GENITALS. 
I.— Penis. 

(1.) Malformations. — (a.) Congenital Phimosis (from ^fy«ow, I 
bind tight). By this is understood a congenital lengthening, and at 
the same time tightening of the prepuce to such a degree that it is 
impossible to retract it over the glans penis. In Httle boys, a certain 
degree of this condition is to some extent physiological, and very rare- 
ly only can the foreskin be pulled back entirely so as completely to 
expose the glans ; still, as a rule, it can be retracted so far as to allow 
the mouth of the urethra and adjacent parts to be inspected. 

If it is impossible in any manner to retract the foreskin sufficiently 
to expose the meatus, then the condition is called congenital phimosis. 
Usually the effects of this condition are trifling, for the orifice in the 
foreskin is generally sufficiently open to allow the urine to flow off in 
a stream. This superfluity of the prepuce decreases with age, the 
apex of the glans at length becomes visible, and with the appearance 
of manhood the entire condition is relieved. 

A marked swelling of the prepuce sometimes originates, partly 
from uncleanliness, partly from external injury, and partly as a result 
of balanitis, which is liable to so close the opening that urine is actu- 
ally unable to pass through the tumid orifice. The foreskin becomes 
expanded like a bladder, and discolored ; the child is very restless, and 
with cries of pain presses out a few drops only of urine through the al- 
most-totally-closed opening. Gangrene of the prepuce has even been 
seen to result from this condition. 

The firm adhesions occasionally met with between the inner 
lamella of the prepuce and glans penis are not congenital, but the 
effects of former ulcerative processes in these parts. 

Treatment. — Mild grades of oedema of the superabundant foreskin 
may be relieved by cleanliness and the application of a little oil. 
In more marked cases, with very small opening, the unnecessary tip 
of the integument may be removed in a very simple manner with the 
scissors. The external lamella of the prepuce then retracts more than 
the tensely-stretched internal one, and a short longitudinal incision 
should therefore be made, splitting it toAvard the base of the glans. 
The lips of the wound will soon arrange themselves pretty closely 



DISEASES OF THE GENITO-URINARY ORGANS. 393 

to each other, or they may be held in juxtaposition by a few serre 
fines. The hgemorrhage and consecutive oedema are but slight, and the 
cure is complete in a few days. 

(/?.) Congenital Paraphimosis. — It occurs with and without 
hj'pospadia, and is the result of a true arrest of development. The 
glans, from the earliest period of embryonic life, are not covered by 
foreskin, are imperforate, and the future meatus urinarius is only 
indicated by a white spot. Very gradually a fold of integument, the 
future prepuce, forms behind the corona glandis, rapidly grows for- 
ward, and soon covers the whole glans. The urethra in the mean time 
has become developed. An arrest of this growth, and the coalescence 
of this rudimentary prepuce with the glans, produce the condition 
known as paraphimosis congenita, or, strictly speaking, a defectus 
preeputii congenitus. It is frequently combined with hypospadia, and 
the frgenulum, in particular, is often so shortened that, during erection, 
the meatus is pulled downward. Von Ammon has made the remark- 
able observation that congenital defect of the foreskin not unfre- 
quently occurs in Hebrew boys. It would therefore seem that an 
artificially-produced defect of form may be inheritable. An analogue 
of this fact is found in the well-known one that tailless pups are 
much more frequently bom in the races of dogs whose tails it is cus- 
tomary to cut oflF, than in other races which are not mutilated by this 
cruel custom. 

No therapeutic measures are necessary in this defect of the penis ; 
but, when the freenulum is too short, and during erections drags upon 
the glans so as to be a source of pain, it may become necessary to 
divide it. 

(y.) Congenital Closure of the Meatus {^Atresia Urethroe). — Either 
the orifice of the urethra only is agglutinated, or closed up by a mem- 
brane, or a larger portion of the urethra is impervious. In the first, 
the urethra, on micturition, is seen to expand up to the point of 
closure, and the defect may easily be remedied by a slight longi- 
tudinal puncture with the exploring trocar ; and in the second case, a 
very rare condition, and almost always complicated with hypo, or 
epispadia, the operation is very difficult, and ultimately the bladder 
will have to be punctured if it is not possible to discover the urethra. 

[^.) Anomalous Openings of the Urethra, Hypospadia and Epis- 
padia. — In hypospadia the urethra is not closed on its under surface 
to the tip of the penis, but presents an open trough, so that the mouth 
of the urethra is not found at the point, but on the under surface of 
the penis. In the milder grades of hypospadia, Avhere the opening is 
in the course of the penis, the individuals sufi"er no other inconven- 
ience than that the stream of urine does not flow directly forward but 



394 DISEASES OF CHILDREN". 

doAvnward. Boys learn to correct this by holding the penis upward. 
In the cases of extreme degree of this defect, not only the whole 
urethra, but also the scrotum and even the perinfeum, is fissured, and 
the bladder terminates directly into this chasm. This condition is liable 
to be mistaKcn for hermaphrodism, especially when the testes have 
remained in the abdominal cavity, as is generally the case. The sex 
in these cases can only be decided with certainty in later years, when 
the sexual characteristics of the individual develop, such as masculine 
voice, masculine form of body, and growth of beard. 

Hypospadia, according to its genetic character, is a true arrest of 
development ; for, in this condition, the urethra does not exist in the 
penis, but is represented in a rudimentary condition as a furrow ter- 
minating at various distances from the widely-separated testicles. 

The attempts to establish a normal urethra, and to close the anom- 
alous orifice by a surgical operation, are rarely successful, on account 
of the urine with its corrosive qualities flowing over the fresh wound. 

By ejnspadia is understood a splitting of the urethra on its upper 
surface, so that its proper orifice is on the dorsum of the penis. The 
fissure is either limited to the glans, or extends throughout the en- 
tire length of the penis, and ectopia of the bladder may be looked 
upon as the highest degree of this malformation, a detailed descrip- 
tion of which has already been given on page 380. It is a much 
rarer condition than hypospadia. When the opening of the urethra 
is situated close to the glans, the child has normal control of the 
bladder, and learns to hold the penis, during the act of micturition, in 
such a position as not to wet its clothing. But Avhen the aperture is 
near the root of the penis, then incontinence usually exists, and all 
the lamentable effects are superadded. Those persons only, who have 
the aperture in the urethra situated so far back that, during the emis- 
sion of semen, none enters the vagina, can be regarded as devoid of 
procreative abilities. 

(2.) Balanitis, Intlammation of the Prepuce (from ^alavog, 
glans). — In large boys the smegma praeputii occasionally accumulates 
in large quantities, becomes hard, and undergoes chemical decompo- 
sition, and then causes inflammation of the glans and prepuce. This 
may also be produced by external injuries and constant playing with 
the foreskin. It may also occur in those who masturbate, and in 
patients sufi'ering from worms. 

The foreskin is then seen to be swoUen, its orifice agglutinated, 
and the most intense pains are induced when an attempt is made to 
retract it. The glans penis appears reddened, covered with pus, and, 
when it is completely exposed, large masses of a cheesy and fetid 
matter fall out from the fold of the prepuce. The cause of this inflam- 



DISEASES OF THE GENITO-URINARY ORGANS. 395 

matory disease is usually removed with these lumps, and in a few 
days it disappears. The cure is accelerated by lotions and com- 
presses dipped in lead-water. 

If the prepuce, on account of too severe oedematous swelling, can- 
not be retracted, the chief cause of this swelling of the smegma cannot, 
of course, be removed. The result will be an indefinite prolongation 
of the inflammation, the formation of abscesses, and even perforation 
of the foreskin. I once treated a boy for a very severe balanitis, whose 
prepuce could not be retracted by any means. Injections of oil and 
warm fomentations, which in other cases caused the oedema to disap- 
pear, proved ineffectual in this case. On the third day a bluish-black 
spot appeared in the vicinity of the frgenum, indicating circumscribed 
gangrene. At this time a bright spot became visible through this 
gangrenous membrane, which, on closer examination, was cut down 
upon and found to be a knot of a thread, which, upon being pulled 
out, proved to be quite long. The inflammation and gangrenous dis- 
ease were arrested by its removal, and the balanitis disappeared. 
This boy, after retracting the prepuce, had tied a thread around the 
glans, which soon swelled up, and then he was unable to untie it. 
The fear of punishment prevented him from confessing his unfortunate 
act, and he had therefore to wait until the thread made its way out in 
the manner described. But, as the gangrene did not involve a portion 
larger than the size of a pea, the effects were of Kttle moment. 

The treatment of simple balanitis is limited to the removal of the 
smegma, subsequent cleanliness, and astringent lotions. There is no 
danger of union occurring between the prepuce and glans penis. 

(3.) AcQUiEED Paraphimosis. — On account of the long, narrow 
prepuce, a paraphimosis originates in children much more frequently 
than in adults. Boys find a pleasure in puUing and retracting it so 
as to expose the whole glans. The narrow aperture of the foreskin, 
gradually and painlessly dilated by the globular glans, now contracts 
behind the corona glandis, and it requires more adroitness to return 
the prepuce in front of the glans than was necessary to pull it back. 
The alarmed child usually seeks to hide its disaster, the constriction 
in the mean time causes a marked oedema and deformity of the penis, 
and the parents, whose attention is finally attracted to it, are ex- 
tremely frightened by this strange form of the organ. If left to itself, 
the oedema of the glans will increase for several days, and the penis 
will become bluish and deformed. Spontaneous, gradual diminution 
in size will, however, take place in time, for the preputial orifice be- 
comes dilated, and the glans ultimately slips spontaneously behind the 
foresldn. I have never yet seen gangrene of the glans result from 
simple constriction of the preputial border. Once, however, from 



396 DISEASES OF CHILDREN. 

constriction by a thread, as has been related. The slight amount of 
danger that attends the first form is, in fact, due to the distensibility 
of the foreskin itself. 

Treatment. — A more gratifying treatment than that of paraphi- 
mosis can hardly be found. The extremely-alarmed mother brings 
what she considers a maimed child to the physician, and, after a few 
minutes, leaves him beaming with joy, for the glans penis, by the 
successful reduction of the prepuce, has been restored to its normal 
form. 

The entire operation of the reduction simply consists in this : the 
aedematous prepuce behind the glans is grasped between the two in- 
dex and middle fingers, w^hile at the same time the glans is pressed 
backward by both thumbs ; a traction of the prepuce forward and a 
movement of the glans backward are thus produced, and the result of 
this manipulation is a gliding of the foreskin over the corona glandis, 
and the latter, in a short time thereafter, regains its normal shape and 
color. In neglected cases, the glans may first be reduced in size by 
allowing a stream of cold water to flow over the organ, and the un- 
avoidable pains attending the reduction are also thereby rendered less 
severe. 

I have met with many cases of parapliimosis, but so far have been 
able to reduce every one of them, and therefore beheve that those 
children's physicians, who advise the use of compresses of lead-water 
and various astringents until a reduction takes place, are not ac- 
quainted -with the above procedure. 

No after-treatment is necessary, for the part, once reduced to its 
proper position, soon regains its normal ibrm. There is also no dan- 
ger of any relapses, for the child who has thus been so terribly fright- 
ened has never any more desire to see his glans penis exposed. 

(4.) Ojtanism {Masturhatio). — This practice, though met with in 
girls, is far more common among boys, and its effects are less signifi- 
cant in the former than in the latter. The term, in boys, is applied to 
a habit of rubbing or kneading the penis with the naked hand. By 
this means it is brought into a state of erection, and finally an ejacula- 
tion of semen takes place if the boy be of sufficient age. Girls titillate 
themselves, either with the finger or some similarly-shaped object, in 
the vagina ; but, as pain, redness, and increased secretion of the 
vaginal mucus, are very apt to result, the habit is often thereby 
promptly arrested in the girl. 

In boys the case is altogether different. They derive such intense 
delight from this practice that, notwithstanding the severest punish- 
ment, and their own best intentions, they are unable to desist from 
these unfortunate manipulations. They thereby become visibly ema- 



DISEASES OF THE GENITO-URINARY ORGANS. 397 

ciated and angemic, and remain backward in their bodily and particu- 
larly so in their mental development ; the integument of the lower 
eyelids turns to a brownish or bluish color ; they have an apathetic 
expression of the countenance and flaccid muscles. They become 
indifferent to amusements which they once enjoyed, and withdraw 
from all society, preferring to be alone, in order to indulge their pas- 
sion. The gait becomes unsteady and cumbersome, and the knees 
fall inward. The emaciation is most strikingly seen on the lower ex- 
tremities and lumbar region, while the penis increases disproportion- 
ately in length and thickness. The pre23uce becomes shortened, and 
is as readily pushed backward as in the adult ; the slightest irritation 
of the penis suffices to induce an erection. The effects of this practice 
upon health are more or less serious, depending upon circumstances. 
Tabes dorsalis and paralysis of the lower extremities are occasional 
though rare effects of this practice. 

Children who are the victims of this practice, either from symp- 
toms or instruction, are induced to exert themselves to their utmost 
to abandon the vice. The success of their effort very much depends 
upon the age at which they have contracted the habit. The later 
they have acquired it, and consequently the nearer they are to man- 
hood, the less severe the effects observed from it. Boys over ten 
years of age, by continual masturbation, finally bring about an ejacu- 
lation of a slimy and probably prostatic fluid ; but, whether this con- 
tains spermatic filaments, has not yet been ascertained, so far as I 
know. The youngest child, so far as I have information, in whom 
masturbation has been observed, was a girl eleven months old. Ac- 
cording to EraffCs description, she alternately pushed both her little 
hands into the vulva with increasing violence and rapidity ; she drew 
up her lower extremities against the body, grinned, and uttered a 
loud cry. This report is unique, and it may be questioned whether 
the child had not an eruption or a foreign body in the vagina, whicli 
gave rise to the acts, as those of mere scratching. 

The majority of boys who masturbate suffer from the above-men- 
tioned effects, but many retain a blooming appearance, and thrive 
both bodily and mentally. House physicians of institutions which 
have large numbers of boys assure me that the majority of confirmed 
masturbators suffer no bodily detriment from it; and many robust 
men, with great procreative powers, who consult me for other indispo- 
sitions, confess that they masturbated for years during their youth. 

Causes. — Tlie most common cause is the imitative instinct of the 
boys. A masturbator shows his curious performance upon his own, 
or perhaps upon the penis of an inexperienced boy, and from that 
hour the latter becomes addicted to this vice. Onanism, therefore, 



398 DISEASES OF CHILDREX. 

occurs mucli more frequently in boys who have been brought up in an 
institution than in those that remain in their own families. 

Every thing that causes erections promotes onanism. Among 
these causes may be enumerated heavy feather-beds, too nutritious 
meat-diet, alcoholic drinks, obscene pictures and stories. It may also 
be directly induced by itching eruptions on the penis, accumulation 
of smegma prasputii, and by ox^Tiris vermicularis, which may crawl 
out of the rectum, and into the vagina, or under the foreskin. 

Treatment. — According to the statements of an experienced physi- 
cian to an institute, nothing can be done with medicines for onanism. 
All that can be done is to render the practice of the evil as difficult as 
possible by exercising a strict surveillance. For this purpose guards 
should be kept constantly in the sleeping-rooms to watch and to 
punish upon detection. The mattresses should be hard ; the cov- 
erings ought not to be feather-beds, but blankets of wool or cotton, 
through which the contours of the body are more easily perceived. 
The children should be punished very severely, yet the cause must be 
kept secret from the rest. It is of the greatest importance that as 
few boys as possible know of this vice, and, for that reason, the speedy 
dismissal of the masturbator is the best remedy against its spreading. 
The utmost care should be taken to eradicate the causes mentioned 
above. It is not politic to examine often and minutely the penis of 
boys who are suspected, but not proven guilty, for the attention of the 
innocent might thus be attracted to it, and they thereby become ad- 
dicted to it. Cold aifusions and baths are very valuable remedies for 
the effects of onanism, such as emaciation and imperfect development. 
Under no circumstances should iodine, or mineral waters containing 
iodine, be employed for the obesity which sometimes appears in these 
children, and on account of which they acquire an extremely comical 
appearance. Iodine given under these circumstances is liable to in- 
duce emaciation and tuberculosis. 

The threatenings which are resorted to by some teachers and 
guardians are, on the whole, very improper; the health is infallibly 
undermined by them, and death soon follows. They certainly often 
induce the boys to stop their pernicious practices ; but they relapse into 
a state of deep melancholy, which follows them up to manhood. Proper 
bodily chastisement serves just as good a piirpose, and this sad mental 
condition is totally avoided. 

II.— Testes. 

(1.) Cryptorchidia (from KpvKTdg, concealed, and opx^c, testicle). — 
In the ninth month of foetal life, the testicles pass out of the abdo- 
men and descend into the scrotum, and a boy at fuU term comes into 



DISEASES OF THE GENITO-TJRINART ORGANS. 399 

the world with both glands in the scrotum. Seven-months children 
are generally delivered with empty scrotums, the testes not having 
yet descended. One or the other testis — seldom both — ^is sometimes 
absent from the scxotum even in children at full term. They remain 
some time in the abdomen, or in the canal before descending. About 
ten per cent, of all boys present some of the forms of this irregular- 
ity. In the great majority of these cases the testicle descends 
without producing any symptoms during the first few weeks of life, 
so that older children are but very rarely met with who have but one 
testis in the scrotum, and still more rarely with none. These persons 
are called monorchides, testicondi, cryptorcliides. The last is the 
most appropriate denomination, for they certainly possess not one but 
two testicles, which, however, cannot be found in their proper places. 
If an opportunity occurs to make an autopsy upon a cryptorchis, the 
retained testis will not be found in its original anatomical place, in 
the lumbar region, in front and below the kidney, but usually at the 
entrance of the canalis vaginahs, or within it, or in front of it in the 
lumbar region, where it may also be detected during life, as a hard 
eUiptical tumor, painful when strongly pressed. 

Nature occasionally completes the descent at puberty — descensus 
testiculi serotinus — a process unattended by any symptoms, and totally 
unobserved. The testicle, however, never descends quite to the bot- 
tom of the scrotum, for the spermatic cord has been shortened and 
prevents it. In other cases a violent bearing-down pain is said to 
occur, and it is even affirmed that persons have died from it. The 
mechanical cause of death, so far as I am aware, has not been very 
clearly elucidated. It is, perhaps, caused by gangrene of the con- 
stricted testis. 

According to Von Ammon, the testicle may also make a false pas- 
sage for itself, and appear in the groin, where it may be mistaken for 
a crural hernia, or it goes to the perinaeum. No other unhappy results 
of cryptorchia occur ; impotence, in particular, is not caused by it. 

This malformation cannot be remedied by any aid of art. There 
is no remedy that will extricate the testicle that has remained in the 
abdominal cavity, and nothing but injury will be done by any attempt 
at accelerating its descent from the canal by the aid of expulsive 
trusses. Compressive means are not advisable, even when a knuckle 
of intestine escapes from the canal at the same time with the testicle. 
The best thing to do in this case is, to wait till the testis has en- 
tered the scrotum, then to reposit tlie hernia, and retain it by a good 
truss. 

(2.) Hydrocele. — A serous double sac, the timica vaginalis pro- 
pria, envelops the testis and epididymis, and in the pliysiological state 



400 DISEASES OF CHILDREN. 

contains but. a few drops of serum, sufficient to lubricate the serous 
surfaces. In hydrocele, an augmentation of this serum distends the 
sac ; its outward surface is nowhere in contact A\4th the inner, and the 
scrotum has undergone a ^-isible enlargement. We designate this 
condition by the name of hydrocele. 

In young children, hydrocele occurs extremely often ; usually only 
one side is affected. In most instances it is indebted for its origin 
to an imperfect closure of the canalis vaginaKs, after the testicle has 
descended to the scrotum. This permits the secretion of the whole 
peritonaeum to descend into the scrotal pouch of this membrane, 
which becomes distended and produces a hydrocele. It is not con- 
genital in the strictest sense of the term, for it originates a few 
weeks or months after birth. But the predisposition to it, the open 
vaginal canal, is congenital, and the same may therefore be said of the 
hydrocele itself. The following four kinds are distinguished : 

(1.) Hydrocele canalis vaginaHs testiculi aperta (PI. III., Fig. 11). 
Tliis form of hydrocele is rarely seen well defined. It appears as an 
oblong tumor, extending from the base of the canal downward to be- 
neath the testicle, which testicle cannot be felt at all, or but indis- 
tinctly ; the spermatic cord, on account of serous infiltration, is dis- 
tended to the thickness of a common lead-pencil. The characteristic 
feature about this form is, that the tumor becomes markedly more 
tense and larger at the moment the abdominal \ascera are crowded 
downward by the act of inspiration, and smaller and softer again with 
the expiration. The same happens when the scrotum is raised up, by 
which its contents flow back into the peritoneal cavity. Sometimes 
this can only be accomplished by the aid of pressure, especially when 
the canal is narrow. This condition is sometimes liable to be mis- 
taken for an external inguinal hernia. The form is the same, and the 
contents likewise reducible. Dropsy of the scrotum, however, is 
markedly translucent, flat on percussion, while a hernia always affords 
a hollow sound, and the testes cannot be isolated in hydrocele as in a 
hernia. Indeed, the manner in w^hich the tumor disappears suffices for 
the experienced diagnostician to distinguish the two conditions with 
certainty. In hernia, the gut retreats suddenly with a gurgling noise, 
while in hydrocele the tumor decreases slowly and steadily, not by fits 
and starts. 

(2.) Hydrocele fundi canalis vaginalis testicula clausa (PI. HI., Fig. 
12). This is by far the most frequent form. Generally it is not con- 
genital, but makes its appearance a few weeks after birth. The tumor 
is round, transparent, and cannot be diminished by pressure. The 
testicle is situated above and behind, and can be felt but imperfectly 
The spermatic cord is perfectly normal. This hydrocele is often hi- 



DISEASES OF THE GENITO-URINARY ORGANS. 40I 

lateral, and then, owing to the uniform enlargement of both scrotal 
sacs, is not so readily observed by the relatives as when one side 
only is affected. 

(3.) Hydrocele colli canalis vaginalis aperta (PI. Ill,, Fig. 13). 
Here the spermatic cord is found filled with water, and dilated from 
its commencement in the abdominal cavity, down half-way, more 
or less, into the scrotal sac, while, in the depth of the scrotum, a 
perfectly-normal testis is distinctly felt. The tunica vaginalis sur- 
rounds the testicle completely, and is dropsically distended in that 
portion above the testicle only. Pressure will reduce the size of the 
tumor; the serum may be forced back into the peritoneal cavity, but 
the spermatic cord, on account of the hypertrophy of the tunica 
vaginahs, never becomes as thin as the one on the sound side. Her- 
nige may readily become superadded to this, and to the form described 
in sub. 1, as the vaginal canal remains open. It is sometimes not an 
easy matter to distinguish this condition from hernia. The disappear- 
ance of the tumor, whether slowly or suddenly with a gurgling sound, 
is the cardinal point in the diagnosis of hernia intestinalis. As this 
form is very rare, however, we are not often likely to meet with the 
difficulty attending its diagnosis. 

(4.) Hydrocele colli canalis vaginalis clausa (PI. III., Fig. 14). 
Here the spermatic cord, at its point of exit from the inguinal ring, is 
of a normal thickness, and continues in this manner for a short dis- 
tance, then suddenly becomes distended to an oblong cyst, which ter- 
minates as abruptly below ; the testis, as in the preceding form, is of 
a normal size and consistence. These conditions are best recognized 
by first ascertaining the locality of both testes, comparing them with 
each other, and then by pulling lightly the testis on the diseased 
side ; by this the examination of the spermatic cord is much facilitated. 
This form occurs tolerably often ; it is usually, however, monolateral. 
It may, indeed, be displaced, as a sound spermatic cord occasionally is, 
and cannot be felt. As a rule, however, pressure does not diminish 
the tumor of tliis condition, for the vaginal canal is closed. 

These comprise the various forms of hydrocele in children. The 
second and the fourth forms are the most common, Avhile the first and 
the third are rarely observed. 

The contents of these hydroceles, if they have not yet been subjected 
to any active treatment, are thin, pellucid, light-yellow serum, having 
the chemical composition of the serum of the blood diluted with water. 
If it has often already been punctiu-ed, or a seton been drawn through 
it, or irritating ointments rubbed in upon it, the fluid that then escapes 
on puncturing it is of a milky turbidness, and exhibits a large number 
of cells. 



402 



DISEASES OF CHILDREN. 



The spontaneous course of all the forms is, although tardy, almost 
invariably favorable. A hernia prolapsed through the unclosed inguinal 
canal is an unfavorable complication, as it is thereby prevented from 
closing, and the absorption of the hydrocele is retarded. In almost 
all the other cases spontaneous absorption of the effused fluid takes 
place in the course of time, although often not till after many months. 
A thickening of the tunica vaginalis propria only remains behind. 
Absorption occurs even in the rare cases of hydrocele which communi- 
cate with the peritoneal cavity; the inguinal ring generally becomes 
closed when the lower extremities are more freely exercised. 

Treatment. — Since almost all hydroceles, in children who have not 
yet passed beyond the first year of Ufe, get well spontaneously, it is 
only a question of promoting this cure by Nature, mth appropriate 
means ; those most generally regarded as such are dry warmth, aromat- 
ic fumigations, astringent fomentations of ammonia and vinegar, wine, 
diluted tincture of iodine, etc., and finally compressing the tumor by 
adhesive plaster or collodium. The congenital open hydroceles heal 
quickest, when their contents are forced back into the peritoneal cav- 
ity and retained there by a truss. The simplest and surest remedy, 
after all, is acupunctvire. This may be performed with any plain 
sewing-needle. The scrotum is made tense over the tumor with two 
fingers, and then it is punctured several times in succession. A drop 
of the serous fluid follows each punctuer, but, Avhile the external 
openings in the skin instantly close again, the perforations in the 
tunica albuginea remain open much longer, and the serum now escapes 
into the other textures, producing an oedema of the scrotum which, 
after a few days, is spontaneously absorbed ; the external and internal 
lamellsB of the tunica vaginahs have in the mean time become so firmly 
consolidated that no future effusion can occur. This little operation 
may subsequently be repeated without any hann, if the first trial be 
not entirely successful. 

Hydrocele in older children, and that of the spermatic cord, disap- 
pear also without any surgical interference, by the simple use of 
iodine locally. 

D.— FEMALE GENITALS. 

(1.) IMalforiiations. — Malformations of the female sexual organs, 
in general, are rarer than those of the male, and with few exceptions 
are only discovered at the time of puberty, for the symptoms which 
thev occasion first appear with pubescence. 

In order to thoroughly comprehend these malformations, it is ne- 
:;essary to learn from embryology that the uterus, Fallopian tubes, 
and vagina, are developed in such a manner, from the canals of IMiiller, 



DISEASES OF THE GENITO-URINARY ORGANS. 403 

that the lower part of the latter is converted into the canalis genitalis, 
and that a transverse indentation then follows, by which it is divided 
into two portions, the uterus and the vagina. For this reason all these 
malformations may be arranged, according to Veit, in two classes: the 
first originates through a defective development of one or both canals 
of Miiller ; the second through an abnormal union of the two canals in 
all other respects perfectly developed. 

First class : (a.) The canals of Miiller have been entirely arrested 
in their development, and therefore neither uterus nor vagina exists. 
The external genitals terminate in a short cul-de-sac. (b.) The vagina 
is present, of a normal length, but the uterus is absent, or it is only 
rudimentarily developed, (c.) Vagina and neck are of normal size, 
but the body of the uterus, owing to the defective coalescence of the 
commencing portions of the canals of Miiller, is divided — uterus bicornis 
— atrophic, and terminates in two atrophic oviducts. (d.) Only one 
of the canals of Miiller is deformed, or totally absent, by which the 
uterus unicornis originates. The corresponding ovary in this case is 
mostly normally formed ; on the whole, however, the ovaries in deform- 
ity of the uterus are generally also defective. 

None of these malformations give rise to any symptoms in chil- 
dren, and, as they produce no external alterations of form, remain also 
undiscovered. But, with the appearance of the menses, various dis- 
turbances come on, and a menstruatio vicaria becomes established in 
some other part of the body. 

Second class : (a.) The uterus is well developed, but its cornua are 
divided — uterus bicornis. (b.) The division runs through the whole 
organ, two vaginal portions project into the single or also double 
vagina, in which case even two hymens may exist, (c) Externally 
no alteration of form whatever, or only a superficial groove, can be de- 
tected on the uterus, but its cavity is divided by a central septum into 
two perpendicular, adjacent compartments, uterus bilocularis. 

Even these malformations have no unpleasant influence upon the 
development of the child, and are almost always only accidentally 
seen in autopsies. A divided vagina and double hymen, however, 
will not escape detection. 

Tlie conditions described as malformations of the external genitals 
usually are not really congenital, but form in the course of years from 
originally normal genitals. This is especially true of the enlarged 
clitoris, and the elongated labia majora, the so-called "Hottentot's 
apron." A partial closure of the external labia occurs besides, in 
gmall girls, who have sufibred from severe deep diphtheritic ulcerations 
of those parts, and were nrt treated with a proper amount of cleanli- 
ness and care. 



404 DISEASES OF CHILDREN. 

( 2.) Catarrh of the Gexital Mucous Membrake {Fluor 
Albus, Leucorrhoeci). — Symptoms. — By fluor albus we understand such 
an augmented secretion, by the vagina and vulva, that tlie discharge 
makes its appearance in drops upon the labia majora, and may flow 
down upon the perinasum and thighs so as to soil the linen, and, drying, 
forms large crusts upon the labia. A secondary redness and swelling; 
are thereby produced, and in summer, if the parts are not kept clean, 
will result in ulceration of the external genitals and adjacent parts. 

At first the secretion is thick, bright yellow, homogeneous, but sub- 
sequently, toward the end of the disease, or in scrofulous girls, from the 
very beginning is viscid, muculent, filamentous, poor in cells, very 
much like the catarrhal mucus of the nose. If ulcerations have already 
formed, the blood derived from that source becomes mixed with the 
mucus and gives it a brownish color. It is not possible in little girls to 
decide the place of origin of this secretion, whether it comes from the 
uterus or vagina, for the hymen is always swollen and a dilatation of 
the vagina by the aid of small specula is very properly reluctantly 
resorted to. The rapid course of leucorrhoea in children shows plain- 
ly that the discharge comes from the mucous membrane of the vagina 
and not from that of the uterus, whereas blennorrhoeas of the uterus in 
the adult are well known to last for years, notwithstanding the most 
persevering treatment. 

If the crusts which agglutinate the external genitals are soaked 
off, and the vulva, external labia, and hymen are examined, they will 
be found oedematous, reddened, and painful to the touch. Urethritis, 
which manifests itself by the flow of pus from the urethra, and by 
severe pain on micturition, is sometimes, but not frequentl}^, present. 
Older girls complain also of pain about the genitals, and walk, espe- 
cially when excoriations are present, with outspread legs, in order to 
avoid friction as much as possible. 

The course of leucorrhoea is always chronic, and I cannot recall a 
single instance that got well under six weeks ; still, there is always a 
better prospect of recovery than in adults. But, in children with ad- 
vanced tuberculosis and hectic fever, I have seen it persist till death, 
in an undiminished degree, and, at the autopsy, that warty granular 
condition of the vagina, which we so frequently observe in old leucor- 
rhceas of the adult, Avas found. 

Causes. — It certainly cannot be denied that infection through 
gonorrhoeal virus occurs even in children a few years old. An unfortu- 
nate superstition exists among the public, that gonorrhoea of the male 
organ disappears when it is brought in contact with a hymen, and 
upon this belief many unchaste seductions are committed. "Whoever 
has frequently examined and watched these unfortunate children will 



DISEASES OF THE GENITO-URINART ORGANS. 405 

nave noticed the singular, embarrassed, shy feeling they are affected 
with. If the simple question be put to them, where did the disease 
come from, ingenuousness vanishes, and they either protest their inno- 
cence with remarkable perfidious vivacity, or are thrown into a state 
of visible embarrassment, and timidly answer, in an undertone, that 
they know nothing about it. If nothing strange can be perceived in 
the conduct of the child, it may be assumed with tolerable certainty 
that no infection has taken place, and a spontaneous or mechanical 
Origin must be regarded as probable. If condylomata are present upon 
the labia majora and around the anus, there is no longer any doubt 
that a true infection has taken place. 

Leucorrhoea originates spontaneovisly, particularly in scrofulous and 
tuberculous children, living in damp houses. It is also produced 
mechanically by the introduction of foreign bodies, or from oxyuris 
gaining admission into the vagina, or lastly by onanism. The funnel- 
shaped condition and marked tumidity of the external genitals, so 
urgently insisted upon in medical jvirisprudence as a symptom of rape 
having been committed, can only be of value after frequent repetitions 
of the act which make the condition well marked. No permanent 
alteration of form, not even any decided contusion or tumefaction, can 
ever originate from the simple contact of the glans penis with the 
hymen. 

Treatment. — It is immaterial in the treatment whether the leucor- 
rhoea has originated spontaneously or from gonorrhoeal infection. In 
both cases cleanliness and daily baths render very important service. 
Those produced mechanically get well quickest — after a piece of 
wood, a bean, glass bead, or some similar substance, has been removed. 
These objects, however, are often concealed behind the hymen and are 
not easily found. The redness and swelling will disappear in a few 
days. 

"V^Tien leucorrhcea is caused by oxyuris, the cure ^s about as easily 
effected by properly syringing the rectum daily with cold water, and 
the vagina, on account of its greater sensitiveness, with warm water. 
The prognosis is much worse when onanism is the cause of this disease. 
On account of the pain it causes, the girls do indeed stop masturbat- 
ing for a time, but they begin their pernicious practice again as soon 
as the irritation and pain have subsided, and thus constant relapses 
are produced, which can only be prevented by the strictest surveillance, 
which has to be continued unceasingly day and night. 

Leucorrhoea that has originated from contact with gonorrhoeal con- 
tagion lasts at least six weeks, and may persist for many months. 
The inflammatory affections, redness, pain, and swelling, are at first so 
severe, that the child is not aljle to walk, and the discharge rapidly 
2T 



406 DISEASES OF CHILDREN. 

excoriates the labia and thighs. The disease is also most obstinate, 
even when not gonorrhoeal, in very scrofulous or far advanced tu- 
berculous children, in whom it lasts for years, and, when hectic 
fever comes on, will continue till death. 

To robust, healthy children, in whom the disease was produced 
by infection, laxatives, jalap, senna, aloes, and neutral salts, may be 
given for a long time with advantage ; cachectic individuals, on the 
contrary, must be treated from the very commencement with tonics, 
iron, cinchona, and meat diet. 

The local treatment, on account of the smallness of space of the 
infantile genitals, is limited to zealous injections of cold or warm 
water, and the introduction of a piece of lint into the vulva at bed- 
time. Much benefit is derived from soaking this compress in a 
solution of alum ( 3 j to water 3 j) or of tannin (3 j to water 
§ j). Sulphate of iron and nitrate of silver are indeed also effi- 
cacious remedies in leucorrhcea ; they, however, totally spoil the 
linen, and are therefore very reluctantly resorted to by economic 
mothers. 

In scrofulous children, sea-baths and the waters of springs con- 
taining iodine (Heilbronn, Kreuznach), likewise cod-liver oil, render 
the best service. Cutaneous diseases, eczema, impetigo, and pru- 
rigo, existing upon the external genitals, must be removed as quickly 
as possible by cleanliness and desiccating ointments, for they are 
constantly bathed by the vaginal discharge, and the two evils act 
injuriously upon each other. 

(3.) H^MOERHAGiA. Vagix.e (Bleeding from the Vagina). — In 
a new-born girl, or in girls a few days old, a slight vaginal hcemor- 
rhage is observed in some rare cases. Usually, the bleeding is in- 
significant, and a few drops only ooze out from between the labia 
during the day. The breasts often swell up at the same time, and 
on moderate pressure will give exit to a few drops of milky fluid. 

Vaginal haemorrhage never becomes profuse, and as such is not 
dangerous ; but, in the two cases that I have had the opportunity 
to observe, profuse intestinal catarrh and atrophy ensued in a few 
days, a condition which, after all, may perhaps more justly be at- 
tributed to the want of the breast of the mother, tlian to the pre- 
ceding haemorrhage. 

Billard and OlUvier d ''Angers have often met with these small 
haemorrhages, but were unable to perceive any bad effects from 
them. 

In exceptional cases, menstruation takes place regularly in very 
young girls. Cases are reported where girls of from eight to twelve 
years of age menstruated regularly, and even became pregnant. 



ERUPTIVE FEVERS. 4O7 

In addition, it has been observed, especially in tuberculous fami- 
lies, that the girls become prematurely mature, often as early as the 
tenth year, whereupon the scrofulous affections that prevailed pre- 
viously undergo a retrograde process, only to be followed by an all 
the more rapid tuberculous development. There is no danger of 
mistaking vaginal haemorrhage for bleeding from haemorrhoids, for 
the latter condition is never met with in infancy and childhood. 
Occasionally, however, fissures of the anus occur, especially in chil- 
dren suffering from constipation, from which some bleeding may 
take place. But, in these cases, the bleeding will always be found 
on the posterior part of the linen, while in haemorrhage from the 
vagina the blood is always on the anterior part of the diaper or 
under-garment. 

Therapeutics. — On account of the insignificancy of the bleeding, 
it does not seem advisable to resort to cold-water injections or the 
introduction of styptics for its premature arrest. It is best to wait 
till it stops spontaneously ; the warm-water baths, however, should 
be omitted so long as it continues. Should the bleeding, however, 
persist, a mild solution of alum, or of tannic acid, injected into the 
vagina with a syringe, will be sufiicient to check it. 



CHAPTER VII. 

SECTION L ERUPTIVE FEVERS. 

All the diseases of the skin occur in children, and most of them 
indeed much more frequently than in adults. As, however, in the 
plan of this work, a knowledge of special pathology, and also of the 
cutaneous affections, is presumed to have been already acquired, we 
limit ourselves to the consideration of those morbid alterations of 
the skin which are almost exclusively observed in children ; or, if 
they also occur frequently in adults, require in children, on account 
of the greater delicacy of the skin, a different treatment. Some of 
the diseases of the skin have already been described in former chap- 
ters, for example : seborrhoea capillitii, page 6 ; sclerema, page 70 ; 
cancer aquaticus, page 97 ; the eruptions during the first dentition, 
page 107 ; in abdominal typhus, page 477 ; naevus vasculosus, page 
210. Other markedly cachectic eruptions will be treated of with 
the cachexise, syphilis, and scrofula, and thus we have only remain- 



408 DISEASES OF CHILDREN. 

ing for this section the acute exanthemata, and a few chronic efflo- 
rescences. 

(1.) Scarlet Fever [Scarlatina). — Scarlet fever, as, in fact, ail 
acute contag-ious exanthemata, is not to be regarded as a simple cuta- 
neous aiFection, but more as a general disease, of wliich the morbid 
alteration of the skin may certainly be looked upon as the most strik- 
ing symptom. It has alwa3's been the subject of attention from 
authors, to such an extent, indeed, that Ganstatt collected a list of one 
hundred and ninety-one works upon this subject, which had been pub- 
lished before 1846. Since that date several dozens of works upon it 
have been added to the list. This large number of treatises is due to 
the ease with which it is observed, its frequent occurrence, and to the 
peculiar fact that almost every epidemic furnishes some slight modi- 
fication, -which in former epidemics was but little and imperfectly 
observed. To simplify the study of this affection, we will first present 
a description of a regular scarlet fever, and all the variations and com- 
pHcations will follow in a special section. 

A.-NOIiMAL SCARLET FEVER {SCARLATINA LEGITIMA). 

Symptoms. — Legitimate scarlet fever runs through three tolerably 
sharply-defined stages : (1), incubation and premonition ; (2), eruption 
and efflorescence of the exanthema ; and (3), its disappearance, with 
final desquamation. 

1.) The Stadium of Incubation and Premonition. — The in- 
cubation lasts from the day of infection till the appearance of the 
febrile chill ; thence the precursory stage is reckoned. This period 
is by no means ahke in all children ; in most instances it lasts from six 
to eight days. Accounts of very great deviations from this are to be 
accepted with the utmost caution, for it is very seldom possible dur- 
ing an ejDidemic to determine the day of infection "wdth absolute cer- 
tainty. The opportunities for infection, by means of personal inter- 
course, especially with still-desquamating convalescents, or by trans- 
mission through a third person, are so variable and difficult to be con- 
trolled, that one may well doubt the statements which vary consider- 
ably from the general average, six to eight days. 

So long as it is not known that the children are infected, no symp- 
toms are usually observed during the period of incubation. But, when 
the parents have once ascertained that their child has been exposed 
to the contagion, from that hour they observe a host of symptoms, 
most of which are of a subjective nature, and furnish a more positive 
proof of parental anxiety than of medical acuteness. Some few cases, 
however, do in fact occur where the children feel unwell from the mo- 



ERUPTIVE FEVERS. 409 

tnent of infection, are aepressed, sleep restlessly, ana have less appe- 
tite, till finally distinct febrile symptoms indicate the commencement 
of the precursory stage. 

The real premonitory stage embraces a period of from one to three 
days. The sjrmptoms which appear during it are always so marked 
that the relatives notice them, yet are by no means on that account 
always the same. They do not, as a rule, possess much that is charac- 
teristic. Slight chilliness, hot and cold flashes, or a shivering chiU, 
heightened temperature of the skin, very rapid pulse, severe thirst, 
anorexia, nausea, and, when the fever appears, sudden vomiting, 
are the ordinary phenomena. There is one symptom, especially 
during the prevalence of an epidemic, which makes the eruption of a 
scarlet fever more than probable, and that is a slight angina, occa- 
sioned by general redness and swelling of the whole posterior part of 
the mouth, palate, and fauces. The additional cardinal points for the 
diagnosis of a scarlet fever are remarkably hot breath, great frequency 
of the pulse, a burning-hot skin, and severe vespertine exacerbations, 
which may become aggravated into convulsions and delirium. 

After these symptoms have lasted one, or, at the longest, three 
daj^s, the eruption begins to break out, and with it the second stage. 

2.) The Stage of Eruptioit and Florescence. — The ex- 
anthema first appears upon the neck and face, then spreads rapidly 
over the whole body, and in twelve hours the eruption is at its 
height. It begins by the appearance of barely-visible, impalpa- 
ble, small red points upon the neck, quickly followed by a marked 
erythema. When the erythema does not uniformly cover the whole 
body, and occurs only in the form of large, red spots upon white, 
normal ground, then this kind is described as scarlatina variegata ; 
when the whole body is reddened, as scarlatina levigata. These two 
forms cannot be entirely separated, for often the one is observed on 
some parts of the body, while the other is seen upon other parts, and 
stiU more frequently the scarlatina variegata at the climax of the dis- 
ease becomes scarlatina levigata. 

Previously-healthy, well-nourished children become, in the true 
sense of the word, as red as " boiled lobster ; " the feebler the pa- 
tients, the less intense will be the erythema. The erythema is 
darkest in the vespertine exacerbations, and during bodily exertions 
or crying, and least intense when the children are uncovered and be- 
come cool. 

Normal, simple scarlatina lasts fully four days. During the first 
two days the redness of the skin and general symptoms reach their 
climax ; in the next two the local as well as the general subside. 

Simultaneously with the eruption of the exanthema, the anginoua 



410 DISEASES OF CHILDREN. 

difficulties become considerably aggravated ; still, the angina of scarlet 
fever is never as severe and painful as a simple tonsillitis with marked 
tumefaction and incipient suppuration. The so-called scarlet-fever 
tongue is also most characteristic after the eruption. Its root and 
centre are covered white, its borders and apex colored dark red, 
the papilloe filiformes are slightly swollen, and give it a granular ap- 
pearance, on account of which, and the similarity of color, the name of 
" raspberry tongue " has not unaptly been bestowed upon it. Occa- 
sionally the papillae are so intensely swollen that they also project 
boldly backward like red points, where the white fur has already 
formed, and thus make the tongue appear villous. 

During the fii'st days the temperature of the skin is very high — 
higher, according to the sense of touch, on those places which are 
reddest. I once found it in the axilla, on the first day of the erup- 
tion, to have risen to 107° F. The pulse is likewise very high, and the 
thirst great. The profound general depression, which sometimes be- 
comes so serious, before the eruj^tion of the exanthema, that the patient 
seems perfectly moribund, subsides after the eruption has appeared. 

Heim formerly claimed that scarlet-fever patients emitted a pecu- 
liar odor. The odor is described as very offensive, and has been com- 
pared to brine, old cheese, or even to that of a menagerie. Possess- 
ing extraordinarily acute olfactory nerves, I have with all carefulness 
sought this supposed specific odor in many patients, but have never 
yet been able to detect it. True, very many children smell unpleas- 
antly, but that is due to the circumstances that the- parents will, un- 
der no consideration, consent to have the linen of the children and 
bedclothes changed; they even set them upon the chamber-pot in 
bed, and often will not touch them with a wet sponge for more than 
a week. From this there results a mixture of odors, to which faeces, 
urine, and perspiration, contribute the chief component parts. This 
so-called specific odor disappears in every instance so soon as the 
anus and genitals have been properly cleaned, the linen changed, and 
the children placed in a fresh bed. 

It is possible that, in Jleini's time, scarlatina was accompanied by 
such an odor ; in our time it is not the case. 

Toward the fourth day, all the local and general symptoms subside 
considerably. The angina disappears entirely, the exanthema fades, 
the fever is limited to the vespertine exacerbations which are growing 
feebler, the children sit up, begin to amuse themselves, and call 
for food. 

3.) The Stage of Desquamation. — The erythema begins to 
fade on those places where it was first observed, on the neck and 
breast, and disappears last from the lumbar region and inner sur- 



ERUPTIVE FEVERS. 411 

faces of the thighs, where the last traces may be seen up to the 
sixth and seventh day from the commencement of the eruption. Pre- 
vious to the desquamation, a profuse perspiration and tolerably severe 
itching break out in most cases, after which the epidermis becomes 
cracked, and is cast off here and there in large scales or laminee. The 
new epidermis during the first few days is of a feeble rosy-red color 
and has a singular smoothness, but soon assumes the qualities of that 
just cast off. The exfoliation progresses upon the fingers and toes 
on a grand scale. It is here sometimes peeled off in continuous 
masses like glove-fingers. A similar process of desquamation also 
takes place on the mucous membranes. The patients hawk and ex- 
pectorate, without much difficulty, a turbid phlegm, the tongue like- 
wise casts off its epithelium, the urine becomes opaque and contains 
enormous quantities of epithehum from the various sections of the 
uropoetic system. Lastly, several large, muculent stools, of a putrid, 
penetrating odor, are also evacuated. 

The desquamation usually begins directly after the exanthema has 
begnin to fade, but may, however, be retarded for fourteen days. This 
happens especially when the recovery is interrupted by some inter- 
current process, for example, dentition or a catarrh of the bronchi, or 
of the alimentary canal, etc. The more intense the erythema, the 
more rapid and thick will be the desquamation. 

This is the picture of legitimate scarlet fever. Its variations are 
numerous, and can never be exhaustively described. They may be 
best regarded from the following points of view : (1.) Incompleteness 
or variations of form of the exanthema. (2.) Modifications in the 
participation of the mucous membrane. (3.) Intensity of the general 
affection ; and (4.) Anomalous localizations. 

B.— VARIATIONS OF SG ABLET FEVER. 

1.) Incompleteness or Modifications of Foem of the Ex- 
anthema. — Erythema of the skin and angina are the principal symp- 
toms necessary to constitute a perfect scarlet fever. When one of 
these two is absent, then we have the variation of an incomplete scar- 
latina, indicated according to the absence of the one or the other: (1), 
scarlatina sine angina ; and (2), scarlatina sine exanthema. 

ad 1.) This form is observed tolerably often. The rash may break 
out perfectly, run a regular course, the desquamation may take place at 
the right time and properly, and yet the patients do not complain of 
any difficulty in deglutition and the tonsils are not swollen, scarcely 
reddened. The general symptoms are here never of especial severity, 
and the affection of the mucous membrane is always slight. 



412 DISEASES OF CHILDREN. 

ad 3.) However easy it may be to diagnosticate the first variety, 
it is by no means so easy to detect tlie second, for it is, indeed, pos- 
sible to mistake it for a simple angina, which children may also ac- 
quire during an epidemic of scarlet fever. The characteristic indices 
in scarlatina angina are : the diffused redness, the raspberry tongue, 
the rarity of suppuration of the tonsils, and the severity of the fever, 
all of Avhich symptoms, however, may also occur without scarlatina, 
in simple angina of a nervous child. Angina of scarlet fever can only, 
then, be diagnosticated with certainty when the same individual has 
already, on a former occasion, been treated for a simple angina, and a 
marked difference in the form of the two fevers is perceived. 

Many authors assert that a child may also desquamate completely 
after scarlatina without exanthema. I have never yet observed this, 
and regard it more prudent, in real desquamation, to assume the exist 
ance of an eruption, although of but a few hours' duration. 

Between these two forms there are, naturally, a number of inter- 
mediate ones. There are whole epidemics where the exanthema is 
comparatively severe, the angina slight, and conversely, epidemics 
where the angina produces very severe symptoms, while the exanthema 
is visible but for a short time, and only on some parts of the body. 

Regarding the form of exanthema, we have, first of all (1), scarla- 
tina variegata / (2), scarlatina levigata. In the former, red patches, of 
the size of a silver dollar up to that of a hand, first appear, which may 
remain separated from each other by a streak of healthy integument. In 
the latter, the whole skin, from the face to the feet, becomes scarlet, 
in which case the desquamation is always extremely intense. At the 
acme of the exanthema the first form will, in fact, run into the second. 

Wlien the exudation of the cutis is considerable, a countless num- 
ber of minute tubercles will arise on the surface of the body, owing to 
which the integument feels rough, like a goose's skin. 

These nodules originate by enlargement of the papillie of the skin. 
This kind is called scarlatina papulosa. 

Lastly, when the exudation is still greater, the effusion will gather 
into vesicles of the size of poppy-seeds, which are scattered in countless 
numbers over the whole body. They contain an alkaline turbid fluid, 
and an extensive desquamation ensues after these have ruptured. 

In some epidemics these vesicles stand so closely together that 
they coalesce, a condition that has been denominated scarlatina vesi- 
culosa, pustulosa, pemphigoida. Miliaries usually form only in very 
well-pronounced, severe cases. 

2.) Modifications in the Participation of the Mucous Mem- 
brane. — That scarlet fever is no cutaneous, but a general disease, is 



ERUPTIVE FEVERS. 413 

seen principally from the numerous affections of the mucoiis membrane 
that accompany it. 

On the usual places, in the cavity of the mouth, the morbid le- 
sions vary extremely in intensity. The palate and tonsils are either 
only simply reddened, or reddened and severely swollen, or in malignant 
epidemics, under unfavorable external circumstances, may become 
covered with grayish-white membranes, forming angina diphtheritica. 
Most frequently the diphtheritic membranes occur upon the tonsils, 
and may be partially detached by gargling, when the mucous mem- 
brane beneath will be seen reddened, eroded, and after a few hours 
becomes covered again with new pseudo-membranes. The odor from 
the mouth is very offensive, deglutition is difficult, and a fetid mucus 
flows from the nose when the diphtheria extends upward into the 
choanse. The adjacent submaxillary and cervical glands are then al- 
ways swollen and occasionally suppurate. The affection of the general 
system is always uncommonly grave, and collapse ensues rapidly when 
the diphtheritis becomes gangrenous ; along with which the odor 
from the mouth becomes intolerably putrid, great difficulty in degluti- 
tion and respiration, delirium or coma, come on, and these are soon 
followed by death. 

The angina likewise shows variations in regard to its extent. In 
benign epidemics, it is confined to the palate and tonsils, but, when 
the diphtheritic form appears, extends also to the Eustachian tubes, 
nasal passages, Highmorian cavities, pharynx and larynx, by which, 
according to the affected parts, deafness, coryza, dysphagia, and 
dyspnoea, supervene. Epidemics with diphtheritic, and, still more, 
gangrenous angina, always belong to the malignant. 

3.) Intensity of the Affectiok op the General System. — 
Our predecessors assumed, (1), an erethitic, (2), a synochal, (3), a 
torpid, and (4), a septic scarlatina. Although this division into dif- 
ferent forms cannot always be strictly carried out, for often several of 
them are observed during the course of the same case, still it must be 
acknowledged that the character of the general reaction may be very 
different in different epidemics. To this variation, that seen individually 
is yet to be added. In general, it may be assumed that the stronger 
and healthier the child was before it was attacked by the scarlet fever, 
the more synochal or violent will be the reaction of its organism ; and 
the feebler and more cachectic, the more septic will be the symptoms. 

By erethitic scarlatina is understood a morbid condition like that 
we have presented above as a normal scarlet fever. The eruption 
and the local and general phenomena appear with no dangerous se- 
verity, and the termination is therefore always favorable. Still, such 
a result cannot always be predicted from the character of the pre- 



414 DISEASES OF CHILDREN. 

cursory stage and eruption, for tlie cHaracter of the fever may change 
at any time. 

Tlie synochal, inflammatory form is distinguished by the rapid 
appearance of the disease, violent fever, intensely-developed exanthe- 
ma, accompanied by miliaries, considerable angina, and cerebral phe- 
nomena, sleeplessness, delirium, headache, and intolerance of light. 

In some epidemics, the torpid or the nervous form is predominant. 
En this case the disease begins from the very first with great prostra- 
tion, vertigo, muttering delirium, syncope, and coma. The pulse is 
extremely rapid, but small, and readily compressed. The angina is 
disposed to take on the diphtheritic form. The exanthema breaks out 
only imperfectly on some parts of the body; the extremities are 
oftener cool than warm. The tongue becomes dry, as in typhus- 
fever patients ; in fact, even profuse diarrhoea comes on, and the pa- 
tients usually die very soon after, or between the second and fourth 
day of the disease. No local causes sufficient to explain the death, 
as a rule, are found at the autopsy, so that we have to assume the 
influence of a supposed scarlet-fever poison upon the blood and ner- 
vous system. When children survive this stage of the disease, they 
are still hable to suffer from its sequelae, and the convalescence in ?1.1 
cases goes on very slowly. 

The septic form may be looked upon as the highest grade of the 
disease in Avhich the eruption usually does not break out at all, and 
the diphtheria of the mouth soon becomes gangrenous, death ensuing 
in the shortest time it ever occurs in scarlatina, and preceded by the 
formation of petechiie, profuse haemorrhage from the nasal mucous 
membrane, from the bowels, and from the kidneys. 

4.) AjStomalous Localizations. — The local lesions are not al- 
ways limited to the skin and mouth. In some epidemics other or- 
gans become involved. Thus it is reported of some epidemics, where 
many children, at the climax of the disease, were attacked by pleurisy 
or pneumonia, and succumbed to them. In others, the children died 
suddenly under tetanic convulsions and severe oedema; even puru- 
lent effusion in the brain was found at the autopsy. Sometimes 
the intestinal mucous membrane participates in a high degree, espe- 
cially at the commencement of desquamation, and profuse intestinal 
catarrh, or dysenteric diarrhoea, with very painful tenesmus, comes 
on. But the most frequent of all anomalous localizations is that upon 
the kidneys, by which acute Bright's dropsy is produced. This has 
already been treated of in detail on page 378. In some epidemics it 
occurs very early in the disease ; in others it is hardly observed at all. 
In the latter epidemics, in Munich, it was one of the greatest rarities, 
and did not appear even among the poorest class, where the want of 



ERUPTIVE FEVErvS. 415 

all care and attention would lead us to expect it with great certainty 
In other epidemics half, and even more, of all the patients became 
dropsical, notwithstanding the best of care and nursing ; and, although 
it cannot be denied that a judicious treatment might possibly be capa- 
ble of warding it off, still it must be confessed that the main cause is 
to be looked for in the character of the epidemic. 

Where the angina is considerable, very generally tumefaction of 
the cervical lymphatic glands, and occasionally parotitis, supervene. 
More details concerning this affection are to be found on page 529, in 
the section which treats of metastatic parotitis. From the same source 
a coryza or an otorrhoea may also become developed by the disease of 
the mucous membrane, particularly the diphtheritic form, extending 
into the nares, or, by implication of the Eustachian tubes, induce an 
otorrhoea interna, which may result in perforation of the tympanum. 

Lastly, metastases on the subcutaneous cellular tissue, with pro- 
fuse suppuration, are also observed, and in the torpid and septic form 
gangrenous bed-sores quickly come on. 

The sequelce of a grave scarlet fever are very numerous. Those 
most frequently observed are chronic serous effusions into the pleura 
or peritonseum after Bright's disease, imbecility, chorea, paralysis, deaf- 
ness, bHndness, and noma, in cachectic children improperly cared for. 

The differential diagnosis of scarlatina and measles will be given 
presently, when we speak of measles. Neither pathological anatomy, 
nor the chemical investigations of the blood, nor of the excretions 
furnish any clew regarding the nature of scarlatina-poison. No con- 
stant morbid alterations, Avith the exception of tumefaction or diphthe- 
ritis of the tonsils, are usually found in the cadaver. 

Etiology. — Scarlatina originates by contagion. It adheres strong- 
est to the scales of the integument which were thrown off during 
desquamation, and for that reason, also, does infection occur most fre- 
quently at this time, and not during the florescence of the exanthema, 
during which it is most possible to transport the disease with the pa- 
tient, and thus limit its extension. On the whole, the epoch with 
which the capacity for infection begins and terminates is not yet 
positively established. Instances are related where children infected 
others during the precursory stage, and some again where infection 
took place long after desquamation had been completed. 

The contagiousness is not equally declared in all cases ; in some 
it is so eminent that all the children of a family fall sick as soon as 
the fever has broken out in one ; in others it is so mUd that the ma- 
jority of the family remain well, notwithstanding frequent intercourse. 
Stall, Harwood, and Mlquel, have performed numerous inoculations 



416 DISEASES OF CHILDREN. 

with scarlatinal blood, or serum, from the miliary vesicles, and fre- 
quently succeeded in producing scarlet fever, vi^hich was as severe as, 
and even more so than, the one employed for the inoculation. If 
only an infection, and no weakening or diminished localization of the 
poison can be attained by the inoculation, then, of course, it fails 
in its object. For that purpose it is not necessary at all to resort 
to this complicated manipulation ; simple contact with the scarlet- 
fever patients is all that is requisite. Children between two and 
twelve years of age are most susceptible to the contagion. Very small 
children are but rarely subject to the fever, and only become aifected 
by it in severe epidemics. The mortality varies from two to twenty 
per cent. Some very reliable authors assert that a person may have 
scarlet-fever twice. This, hoAvever, seems to occur so very infrequently 
that there is a greater reason to assume an error in the observation — 
which, on account of the diagnostic difficulties of some cases, is very 
excusable — than to believe in the actual occurrence of such instances. 

Treatment. — In consequence of the variation of the individual 
epidemics, it is impossible to prescribe one system of treatment that 
would be applicable to all scarlatinas ; moreover, this variation de- 
stroys all faith in the many remedies lauded as specifics. 

It is useless to name here the numerous prophjdactic remedies, 
since none have actually proved to be such. The only rational prophy- 
laxis consists in an entire isolation of the children from all scarlatinal 
patients and all persons who come in contact with such patients. This 
isolation must last at least from five to six weeks for each patient, but 
how far and in what roundabout ways the fever may be transported by 
a third person, it is altogether impossible to say. In grave epidemics, 
in which a majority of the patients perish, it is best for the children 
to leave the city altogether, but that is frequently attended by great 
sacrifices, as the epidemics often rage for a long time and simultane- 
ously in many cities. 

The treatment of scarlatina is either attempted with specifics and 
methods, or it is simply expectant and controlled by the symptoms. 

To the specific remedies belong : carbonate of ammonia, 3 j — 3 ii, 
in a § V solution — chlorine-water, 3 j, in an 3 viii solution ; the mineral 
acids ; acetic acid, 3 ss — 3 j pro die. 

The specific methods were, and in part are still : general abstrac- 
tion of blood, emetics and aperients, and cold affusions — infrictions of 
fat, often eulogized and again forgotten, and lately urgently recom- 
mended by Schneemann^ in conjunction with cooling treatment. The 
methodical cold-water treatment, it is true, has not produced the harm 
dreaded by the older physicians, but in grave epidemics it has proved 
to be totally inefficacious. This author causes the entire body of the 



ERUPTIVE FEVERS. 41Y 

patients, with the exception of the head, to be rubbed with lard, from 
the first day on, for three weeks, morning, noon, and evening ; in the 
fourth week once a day only. With this, the temperature of the room 
should not be above 60° F. ; the bed protected from cold during the 
eruption only, coohng drinks so long as the fever lasts, and internally 
no remedies are to be given. Schneemann very justly lays great 
stress upon thorough and often-repeated ventilation, but carries his 
cooling treatment somewhat too far when he advises the temperature 
of the room to be reduced to between 57° and 59°, and the windows 
of the sick-room to be kept open three hours every day.* 

It need hardly be stated that these specific remedies and specific 
methods have no specific efi'ect whatever, and all of them, in grave 
epidemics, are set at defiance by the virulence of the scarlatinal poi- 
son. In milder epidemics, those remedies are best which torture the 
children least, and husband their enfeebled strength. Of all the reme- 
dies, the preference should therefore be given to a diluted mineral 
acid ; of all the methods, to a moderate infriction of fat. 

The expectant treatment of the symptoms is limited to the removal 
of the patient from all noxious agents, and to the palliation of the 
particularly grave symptoms. 

Proper ventilation of the sick-room is always the best guarantee 
of a favorable course. This is carried out to the greatest perfection 
when two adjoining rooms are devoted to the use of the patient, and 
he spends half the day in one, and half the day in the other room. 
The temperature of the room should be 60° F., so long as the exan- 
thema lasts ; after it has grown pale, or if it did not become properly 
developed, the temperature should rather be raised than diminished. 
The garments of the child and bedclothes should be so arranged that 
it is not kept in a constant state of perspiration, but yet so as not to 
be chilled. The diet, so long as the fever lasts, should be antiphlo- 
gistic ; where constipation exists, a mild aperient, of some composition 
which the child wiU readily take, should be employed ; and, where there 
is a disposition to diarrhoea, constipating soups and mucilaginous 
drinks should be given. When the fever is gone, such a scanty diet 
will vastly retard convalescence ; and no apprehension need be enter- 
tained in regard to the use of mild, easily-digested, plain articles of food. 

When desquamation has been in full progress for several days, its 
completion may be accelerated by a few baths, given with great cau- 
tion, after which the patient may be gradually taken out into the free 
air. In order to guard against all possible reproach, it is well not to 
allow the patients to go out of the house for six weeks ; but this, of 
course, cannot be accomplished among the lower classes, and where 
the care of the children is neglected. In normal scarlatina any simple 
* See treatment of typhus fever, page 493. 



418 DISEASES OF CHILDREN. 

slightly acidulous, saline, or mucilaginous drinks may be given inter- 
nally as a vehicle for amnion, carb. 3 ss, daily, in cases where the ex- 
anthema is imperfectly developed. In the treatment of symptoms, it 
is well to observe that, in some of the gravest and most threatening 
ones, neither hasty nor too energetic measures should be adopted. 
The violent fever before the eruption may tempt us to resort to the 
abstraction of blood, or to the use of calomel ; but we should always 
bear in mind that the course of the disease is likely to be retarded 
by these measures, while the fever is not made to disappear. 

Where the erujotion is very much retarded, an attempt should be 
made, by the aid of sinapisms, sponging of the body with warm water, 
vinegar, or lye, to hasten its progress. Where the rash is already de- 
veloped, infriction of lard is the most advantageous treatment, by 
which the annoying itching is palliated, and the protection against any 
sudden cooling of the sldn is effected. 

Threatening cerebral symptoms, delirium, stupor, or coma, are ma- 
terially relieved by very cold aflFusions of the closely-shorn head, which 
must be repeated every hour. In the torpid, septic form, the powers 
of the system should be sustained by quinine, camphor, wine, musk, 
and castoreum. 

In malignant diphtheritic anginas an energetic local treatment, 
by insufflation of impure flor sulphuris, or inhalation of lime-water 
or diluted lactic acid, would be very beneficial. But the prostra- 
tion of the patients and their resistance form great obstacles to this 
part of the treatment. For the same reason it is but seldom possi- 
ble to employ gargles, and we have therefore to limit ourselves to 
the administration of such internal remedies as are regarded as spe- 
cifics. The best of these are carbonate of soda and chlorate of po- 
tassa ; the first has a really favorable effect in cleaning the mucous 
membrane, the second destroys the putrid odor. Both are given 
separately, dissolved in water, a drachm of each daily. 

The treatment of albuminuria has already been spoken of on a 
former occasion, likewise that of parotitis after scarlatina. Intestinal 
catarrh must be relieved as rapidly as possible by the aid of opium, 
and mucilaginous and astringent remedies. Paralysis and convulsions 
call for the treatment prescribed for these affections on pages 328 and 
320. Consecutive inflammations of the joints and serous effusions 
improve by the aid of warm anodj^ne cataplasms and resolvents. 

(2.) Measles {3forbilli). — By measles is meant an acute conta- 
gious eruption of the skin, which manifests itself by small, round, red 
spots, attended by catarrhal phenomena, and terminates by a furfura* 
ceous desquamation of the epidermis. 

Since the individual epidemics of measles, just like epidemics of 



ERUPTIVE FEVERS. 419 

scarlet fever, present marked variations, and are very different in their 
course, their danger, and in their sequelse, it will be more advanta- 
geous to first give a description of a normal case, and then to speak of 
its modifications. 

K.— NORMAL MOBBILLI. 

(1), A stadium of prodromata; (2), a stadium of eruption; (3), a 
stadium of florescence ; and, (4), a stadium of desquamation, may be 
distinguished with tolerable precision. 

1.) The Peodeomata Stage {Stadium, Invasionis). — In robust 
children and mild epidemics, the prodromes are not so violent as to 
cause the children to take to bed, or to present any signs of a serious 
disease. The most common difficulties are : catarrh of the nose and 
sneezing, with consecutive swelling of the nasal mucous membrane, 
reddened conjunctivee, lachrymation, slight blepharitis, intolerance of 
light, hoarseness, and a dry, barking cough. The general symptoms 
are reduced to languor, prostration, anorexia, slightly-increased tem- 
perature of the skin, thirst, and vespertine exacerbations, which, in 
nervous children, may attain to delirium at night. The tongue is 
coated, taste bad, and pressure upon the stomach painful. Occasion- 
ally the febrile sjrmptoms decline somewhat after a profuse epistaxis. 

All these symptoms increase in intensity from day to day, and 
usually manifest themselves only a few days after infection occurred. 

According to Kerschenstemer''s accurate observations, a period of 
from ten to twelve days always intervenes between the day that the first 
child in a family is attacked by measles and the day the other children 
to whom he gives the disease fall sick. Pammi^ who under extremely 
favorable circumstances watched an epidemic of measles on the Faroe 
Islands, assumes a stadium of precisely fourteen days. But, since we 
know that the exanthema also infects as soon as it has appeared upon 
the sldn, it may therefore be assumed with great probability that 
the children who subsequently fell sick carried about them the mor- 
billi poison for from ten to fourteen days. The prodromes do not 
come on till from three to five days before the actual breaking out 
of the exanthema, and hence it is clear that the morbilli poison re- 
mains perfectly inert for the first six or seven days after its reception. 

2.) Stadium Eruptionis. — The exanthema first appears on the 
face, cheeks, or dorsum of the nose, and from these places creeps over 
the neck to the trunk, on the upper, and lastly on the lower extremi- 
ties. In previously healthy children, the eruption is completed in 
twelve hours ; in general, however, it progresses slower than that of 
Bcarlet fever. 

The exanthema begins with faint red, small round spots, of tho 



420 DISEASES OF CHILDREN. 

size of a lentil. These constantly grow redder — coalesce, when they 
stand close together, into irregular figures ; still there is always some 
intervening normal integument. As they increase in redness, they 
also grow in height, and become elevated over the level of the skin, 
and, when they have attained to their utmost height, turn somewhat 
yellowish, but never form vesicles. Similarly red, elevated spots 
of the skin are present in genuine variola, which last for several 
horn's, and cannot be distinguished from those of measles. But the 
general symptoms in these two exanthemata differ vastly, and genuine 
variola is hardly ever met with nowadays in civilized countries, on 
account of compulsory vaccination. 

The red, elevated spots feel rougher than the normal integument, 
and the hand in passing over them perceives a very peculiar feel of 
unequal hardness. The mucous membrane of the mouth, in fact, also 
displays some unequally red spots, but here the exanthema is by far 
less distinct than in scarlatina. 

The general symptoms reach their climax with the breaking out 
of the fever ; most of the patients are delirious, very restless, and mis- 
lead one to suspect a very grave disease. The bowels are constipated ; 
the urine is dark red, rich in uric acid and urates. 

3.) Stadium Floeescexti^. — Measles are visible on the skin for 
four days ; the fever and mucous-membrane symptoms continue in 
a moderate degree, but the general disturbances visibly decline. 
The eruption fades in the same order of procession as it appeared, 
namely, first in the face, next on the trunk, and lastly on the ex- 
tremities. The greatest amount of tension and swelling is seen on 
the second day after the eruption ; by the fourth these have subsided. 
The integument sometimes becomes yellowish before it returns to its 
normal color, and by the fourth day only indistinct traces of the 
faded exanthema are seen. The conjunctivitis and nasal catarrh also 
improve, while the bronchitis, on account of the great extent of the 
ramifications of the respiratory mucous membrane, often continues for 
a long time, and even in a severer degree than at the beginning. Here 
the expectoration is very considerable. As soon as the exanthema 
has faded on the whole body, the skin begins to desquamate, and the 
process is known as the 

4.) Stage of Desquamation^ {Stadium Desquarnationis). — 
Wlierever the eruption occurred, there the epidermis is thrown oflF; 
not, however, as in scarlatina, in large laminae, but always only in 
very small scales, which often lie upon the skin like a white dust, and 
is best seen when it is rubbed with a black cloth. The more abun- 
dant the exanthema, the more whitened and dusty will the cloth 
become. Tlie mucous membrane of the nose and eyes is now per 



ERUPTIVE FEVERS. 421 

fectly free, but that of the bronchi, even in normal measles, discharges 
a considerable quantity of secretion for several weeks by coughing. 

The general condition improves remarkably quickly, so that it is 
scarcely possible to keep the child in bed for more than three or four 
days after the exanthema has faded. With the exception of the 
cough, that annoys them but little, these patients are now entiiely 
free from all morbid derangements ; they sleep well, their appetite is 
excellent, the stools and urine are normal, and the strength, which 
had been considerably reduced by the disease, is recovered in a few 
days. This is the picture of a normal case of measles, as seen, in any 
moderate epidemic, in an otherwise healthy child. 

-&.~VARIATI0N8 AND SEQUELS. 

These are (1), deviations in reference to the exantbema ; (2), in 
reference to the mucous membranes; (3), in reference to the general 
affection; and (4), a hst of frequent and malignant sequelse. 

1.) MoDiFicATiOK OF THE ExANTHEMA. — The exanthema does 
not always appear in the order above described. In the nervous, 
irritable child, especially when covered with superfluous clothing, it 
breaks out as early as the second day after the appearance of the pro- 
dromata, and often departs from its usual order of progress. It may 
appear first on the extremities instead of the face : the small, red dots 
may coalesce in some places, and then it becomes difficult to distin- 
guish this eruption from that of scarlatina. These larger spots, 
however, are never difiiised over the whole body, and, besides, they 
always possess points sufficiently characteristic of measles not to be 
confounded. An eruption of vesicles, the so-called miliaries, also 
sometimes appears in the course of measles — still much more infre- 
quently than in scarlatina. When it does occur, however, the des- 
quamation is always more abundant, and larger laminae are cast off. 
In malignant epidemics, the exanthemata become bluish, and do not 
entirely disappear, but leave behind them ecchymosis, and are com- 
plicated with malignant affections of the mucous membranes. 

The florescence may be variable in duration. Sometimes it lasts 
only for two or three days, but it may also be seen for five or six days, 
and it is even reported to have totally disappeared and returned again 
in a few days with renewed fever. 

2.) Participation" of the Mttcotjs Membranes. — The mucous 
membranes are much more extensively and intensively affected in 
morbilli than in scarlatina, and danger is more frequently to be appre- 
hended from that soiirce than from the morbilli poison. 

The ordinary conjunctivitis may become a pernicious blennor- 
rhooa, with severe oedema of the lids. The nasal catarrh may give 
rise to such an irritation of the raucous membrane that incessant 
28 



^22 DISEASES OF CHILDREN. 

sneeziiicr, marked congestion of the head, and exhaustion, finally en- 
sue. The inflammation of the palate and glottis sometimes occa- 
sions such an unceasing irritation and coughing as to cause true 
paroxysms, not unlike whooping-cough, accompanied with vomiting 
and hemorrhage. In malignant epidemics, it becomes more than 
simple congestion and catarrh of the mucous membrane. Diph- 
theritic membranes soon form, by which perforation of the cornea, 
and gangrene of the lids, fetid coryza, and salivation may result. 
And, when the mouth and larynx are invaded, salivation and urgent 
croupous symptoms come on. Lobar and lobular pneumonia are 
extremely frequent in measles, and these in particular destroy a 
great many children under one year of age. The intestinal canal is 
much less frequently implicated in this disease than the respiratory 
organs ; still, diarrhoea, of a very pernicious character, also occurs 
sometimes. The uropoetic system, quite different from scarlatina, 
wherein nephritis and albuminuria are the most frequent complica- 
tions, rarely becomes affected in measles. In girls, diphtheritis of 
the vagina occasionally occurs, which usually eventuates in gan- 
grene of the labia and death. 

(3 ) Character of the Fever. — Same as in scarlatina : (1), 
an erethetic ; (2), a synochal ; (3), a torpid, and (4), a septic char- 
acter, which may manifest itself in whole epidemics as well as in 
individual constitutions. Everything that has been said upon this 
point, as relates to scarlatina, is equally applicable to measles. 

The erethetic form is the usual one, and has been described un- 
der " A.— Normal MorhilU:' None of its symptoms become grave ; 
the eruption comes and goes at the right time, and is of moderate 
intensity ; the affections of the mucous membrane, the fever, and 
the cerebral symptoms, are within proper bounds, and there follow 
no sequelae of import. When the vascular excitement becomes very 
considerable, the synochal inflammatory character is assumed. In 
most instances it is ushered in by a violent precursory stage. The 
inflammatory affections of the mucous membranes are very severe, 
the skin becomes burning hot, and the whole body instantly dotted 
with dark-red, prominent spots. The cerebral symptoms look very 
threatening ; wild delirium alternates with profound soporific sleep. 
The intensely-developed exanthema, in most instances, last longer 
than four days, and may be distinctly perceived on the fifth and 
sixth days. The desquamation, corresponding to the preceding in- 
tense cutaneous congestion, is very marked. Consecutive affections 
are frequently observed. 

In malignant epidemics, and in cachectic and especially scrofu- 
lous children, the torpid character of the fever is most marked and 
frequent. Here the precursory stage is protracted by grave symp- 



ERUPTIVE FEVERS. 423 

toms, and an extraordinary rapid exhaustion is noticeable from the 
very first. The patients complain of vertigo and pains in the limbs, 
and are fearfully anxious, restless, and sleepless. The pulse is very 
much accelerated, and small and easy to compress, which, with 
vomiting, profuse diarrhoea, and croup-like paroxysms of coughing, 
present a list of symptoms which, even before the eruption of the 
exanthema, give reason for a very unfavorable prognosis. The ex- 
anthema itself, in this form, seldom appears at the right time, prop- 
erly developed. It disappears again directly after its appearance, 
is only seen on some parts of the body, and never attains the usual 
vivid-red color. The mucous membranes are very much disposed 
to diphtheritic inflammation. Profuse diarrhoea, malignant bron- 
chitis, croup, and simple enervation, without any demonstrable mor- 
bid lesions, sometimes terminate life. An eruption of measles, pre- 
senting the highest grade of this character, constitutes the septic or 
putrid variety. The eruption appears irregularly, and soon becomes 
complicated with ecchymosis. Coma and syncope are the most 
prominent cerebral symptoms. The diphtheritic mucous membrane 
is prone to gangrenous action, and in girls this soon extends to the 
vulva. Profuse nasal and intestinal hasmorrhages may soon induce 
a high degree of anaemia, or even scorbutic condition. This putrid 
or torpid character is by no means always present from the com- 
mencement. It also happens that measles, which at first appeared 
as synochal, alter their character entirely, in the course of a few 
days, to that of the putrid variety, and, for this reason, this distinc- 
tion of different forms has less accurate scientific than practical 
therapeutic value. 

(4.) Sequels, — The most frequent, and, at the same time, the 
most serious sequel of measles, is tuberculosis. Sometimes it devel- 
ops very rapidly and intensely as miliary tuberculosis, so that the 
patients never recover enough to leave the bed, but continue to 
suffer from fever, and to cough and emaciate from the time the ex- 
anthema disappeared. Generally, however, a lengthy interval is ob- 
served between the disappearance of the eruption and the appear- 
ance of the first tuberculous symptoms. These children get up 
again, are free from fever, have good appetite, and the measles is 
forgotten. A slight bronchitis, however, has remained, and per- 
sists, in defiance of the best nursing, uniform terapei-ature, and the 
numerous expectorants. Yery gradually, vespertine exacerbations 
are noticed, followed by general indisposition, loss of spirits and 
strength, and with this the cough increases in severity. The ema- 
ciation becomes more and more marked, the tuberculous phenomena 
are soon physically demonstrable, and, in most instances, rapidly 
advance to a fatal termination. Their jirogress is rarely arrested, 



424 DISEASES OF CHILDREN. 

but, when this does occur, such children will for years be prone to 
bronchitis, and will often experience new tuberculous attacks. A 
more detailed description of the symptoms belonging to this con- 
dition is to be found in the section on pulmonary tuberculosis, page 
569. Otorrhoea is another consecutive disease, and, in most in- 
stances, is complicated with tuberculosis, and often resists the 
astringent treatment for many months. Impetigo and eczema of 
the face, and of the scalp, especially behind the ears, are also very 
common sequelae. In scrofulous children, chronic inflammation of 
the eyes, particularly blepharitis, remains for a long time. Some- 
times the diphtheria occasions very protracted hoarseness, or a 
croup, which, however, in general, aifords a somewhat more favora- 
ble prognosis than pure fibrinous croup. Intestinal catarrhs likewise 
occur, seldom, however, become colliquative, and are quickly ar- 
rested by a judicious diet and proper astringents. In badly- 
nourished, cachectic children, noma also occasionally supervenes. 
The remaining lesions represented as sequelae, such as hydrothorax, 
ascites, pericarditis, meningitis, etc., occur so rarely, that one is led 
to doubt whether he should ascribe any direct connection between 
them and measles. At the autopsy, lobar and lobular pneumonia, 
diphtheria of the mouth and its effects, intestinal catarrh, gangrene 
of the vulva, etc., are found, but neither in the blood nor in any 
organ can any alteration be discovered that will furnish a clew to 
the nature of measles. 

Diagnosis. — Measles may be confounded with scarlatina, ery- 
thema, and exanthematic typhus. As regards the exanthema of 
exanthematic typhus, such as prevailed in the western provinces of 
Russia, Poland, and East Prussia, in many cases cannot be differ- 
entiated from measles. But the course of typhus roseola and the 
period of invasion are more variable. In the same typhus epidemic 
patients are seen in whom the exanthemata lasts nine days, in oth- 
ers only two days, now appearing on the third, and then again on 
the eighth day. In the face, typhus roseola is very rarely seeji, 
morbilous roseola regularly. The markedly typical course, the char- 
acteristic symptoms, the catarrh, and the fever, are sufficient to pre- 
vent mistakes from being made. Very many new-born children, 
and infants a few weeks old, are attacked by a fine punctated ery- 
thema, diffused all over the body, which differs in no respect from 
the eruption of measles. This is, most probably, produced by 
mechanical causes ; the young, delicate cuticle, not yet sufficiently 
accustomed to the contact of the air, baths, and clothing, becomes 
irritated, and its jmpillre inflamed and enlarged. This exanthema, 
in most cases, lasts for several days, vanishes, returns occasion- 
ally, but ordinarily is not complicated with catarrhal symptoms. 



ERUPTIVE FEVERS. 



425 



If these accidentally happen to be present, the whole affection 
will not run such an exactly rhythmical course, and is not ush- 
ered in hy such violent fever, as ushers in measles. Moreover, 
erythema of the new-born child occurs without any contagion. This 
is particularly instructive when taken in connection with the circum- 
stances that new-born children are far less susceptible to the mor- 
billi contagion than older ones, and usually escape the disease, al- 
though it may be in the same house with them. 

The differential diagnosis between measles and scarlet fever is oc- 
casionally attended by difficulties, especially when both diseases pre- 
vail simultaneously in the same locality. It may, therefore, prove 
useful if the principal symptoms and distinctive characteristics of both 
exanthemata are once more enumerated side by side. 



■DIFFERENTIA!. DIAGNOSIS. 



MOEBILLI. 



The precursory stage lasts from 
three to four days. 

The most constant of the precur- 
sory symptoms are : conjunctivitis, in- 
tolerance of light, nasal and bronchial 
catarrh, sneezing, snuffling, hoarse- 
ness, coughing. Frequency of the 
pulse and the temperature of the skin 
but slightly augmented. 

The exanthema consists of small, 
roundish, red spots, slightly elevated 
above the skin, and only on very few 
places coalesce and form larger, un- 
equally-elevated patches. It breaks 
out first on the face. 

As soon as the rash has broken 
out, all the critical general symptoms 
disappear. 

The exanthema of measles, in gen- 
eral, lasts somewhat longer than that 
of scarlatina. On the fourth day it is 
very distinctly seen ; on the fifth and 
sixth it is often still present, though 
less distinct. 

Desquamation in a fine, white 
powder. 

Sequelfe : tuberculosis, bronchitis, 
inflammations of the eye, croup, and 
pneumonia. 



SCAELATINA. 

The exanthema breaks out on the 
second or third day. 

The catarrhal symptoms are almost 
totally absent. On the other hand, 
marked dysphagia is present, due to 
swelling of the tonsils. The fever is 
intense before the eruption of the ex- 
anthema. 

The eruption, in most instances, 
covers the entire body, or at least 
covers large, flat, irregular patches. 
It is most intense on the parts of the 
body of the child which are covered. 
It begins on the neck, and usually 
spares the face. 

Fever and angina continue un- 
abated during the florescence. 

The exanthema of scarlet fever, as 
a rule, is completely gone on the fourth 
day. 



Desquamation in large laminffi. 

Sequel* : nephritis, dropsy, paro- 
titis, and otorrhoea. 



426 DISEASES OF CHILDREN. 

Notwithstanding these differential cardinal points, the diagnosis 
in some cases remains doubtful, and for this reason also totally u^^- 
authorized names have been invented, such as scarlatina raorbillosa, 
and morbilli scarlatinosa. The prognosis, as given in most cases, 
is too unfavorable in scarlatina, and too favorable in measles, for 
all the apparently recovered patients should not be regarded as 
actually cured, as tuberculosis, which very often develops after meas- 
les, and goes on unchecked, carries off many ; thus, if the observa- 
tion were only conducted far enough, it would be seen that the 
ratio of mortality is not so very favorable after all. To repeat, very 
few children die during the florescence or immediately after the 
desquamation, especially if they have already passed the first year, 
but then the subsequent tuberculosis always attacks several per cent, 
of all ages. 

Etiology. — Measles is contagious to a high degree, so that by us 
in Munich almost every person who is not yet impregnated with the 
virus is attacked by it. The contagion is extremely subtile, and no 
direct contact with morbilli patients is at all necessary for an infection. 
Occasionally it is very easy to prove its having been transmitted by a 
tliird person. 

Most of the attempts at vaccination with the blood of morbilli pa- 
tients, whose exanthema was at the stage of florescence, are said to 
have taken efi'ect, and tolerably benign, normal measles appeared be- 
tween the seventh and tenth day. But, as the process was not there- 
by localized, and the course being about the same as when the children 
have been accidentally infected, these inoculations have therefore no 
practical value whatever. 

The contagion of morbilli does not prevail to the exclusion of all 
other infections. Thus varicella, small-pox, and intermittent-fever 
patients, have been seen to be aS'ected with it. When scabious pa- 
tients get measles the scabies usually heals spontaneously and remark- 
ably quickly ; due, perhaps, to the itch animalcule perishing by the 
contaarion or the material alteration of the cutis. 

Finally, the remarkable connection between measles and whooping- 
cough is yet to be mentioned. It has been observed that the conta- 
gion of one relieves the other, measles being particularly often followed 
by whooping-cough, and a certain relation between the two afi"ections 
might readily be assumed to exist. 

Treatment. — We have no specific remedy for the contagion of 
measles. All those measures hitherto suggested have not stood the 
test. Inoculation, as already stated, is not practicable, for, that which 
is obtained with much labor the children usually acquire themselves, 
namely, normal measles. Isolation of the patients afiected with 
measles, and all persons who have any intercourse with them, is the 



ERUPTIVE FEVERS. 427 

only sure means of preventing infection. But, dunng the prevalence 
of an epidemic, this can only be done by a change of place, and is 
principally indicated in pronounced cases of tuberculosis, in which 
measles invariably induce a rapid advance of the cachexia. 

The simple and regular measles require an entirely expectant 
treatment. Energetic measures, such as abstraction of blood, tartar 
emetic, or laxatives, in many instances impede the uniform course, 
without removing the danger or threatening symptoms against which 
they have been employed. 

The best protection against an irregular course and against sequelie 
is a uniform, tolerably high temperature of the room, 65° F., so long 
as the children are in bed, 67° F. when they are about to get up. 
The patient should not leave the bed as long as any trace of the erup- 
tion is still to be seen, and should be confined to his room for at least 
two weeks, and in unfavorable seasons of the year for a still longer 
time, after the eruption has totally disappeared. 

Heavy featlier beds, under which, according to the old style, pa- 
tients were kept covered up to the chin, induce too much perspiration, 
rendering them liable to take cold with all the greater certainty. 
Horse-hair mattresses and plain woollen blankets answer every purpose. 
It is of the utmost importance to ventilate the room thoroughly, and 
that can be best accomplished when the patient has two adjoining 
rooms for use. Children reared in a cleanly manner find it very 
disagreeable to pass several days without having their faces and hands 
washed, a management which is still prescribed by many older physi- 
cians. All the morbilli jDatients that I have treated were washed, face 
and hands, twice a day with lukewarm water, and I have never per- 
ceived the least bad effects from this practice. This useless torture, 
the deprivation of washing-water, should therefore be totally dis- 
carded. The diet should be absolutely antifebrile, so long as any 
traces of fever are perceptible. To forbid food when the appetite has 
returned is cruel, and only retards the convalescence. Children never 
make themselves sick by eating bland, unsweetened nutriments, such 
as milk, soup, and wheat-bread. Where there is a disposition to 
diarrhoea, constipating food must be allowed ; but, where constipa- 
tion exists, mildly-opening nutriments and drinks should be given. 

The treatment of irregular measles, of complications, and of se- 
quelae, is a problematical one, for no really marked effects have been 
observed from almost all the remedies recommended. 

Measles with marked synochal, inflammatory character, tolerate 
very well 3j — 3ij of nitre ; serious head-symptoms in very robust, 
older children are very quickly subdued by a few leeches. In the 
torpid, nervous form, mineral acids, cinchona, and wine, are indicated. 
Severe cough is palliated by narcotics, belladonna, bitter-almond- 



428 DISEASES OF CHILDREX. 

water, or opium. Grave cerebral symptoms call for cold affusions of 
the closely-shorn head. Exanthemata that have disappeared too 
rapidly, or been retarded, are best treated by counter-irritants, sin- 
apisms, and the like. Clysters with diluted vinegar have also been 
recommended for that purpose. 

Severe diarrhoea must, in all cases, be controlled by opium and 
astringents ; slight diarrhoea, in otherwise well-nourished children, 
exercises a favorable influence upon the cerebral symptoms. 

The diphtheritic affections of the mucous membranes improve 
under the internal administration of chlorate of potassa, in large 
doses, at least 3ij — 3iij pro die. The local treatment by the use 
of nitrate of silver or other escharotics is totally useless, and is now 
generally discarded {vide treatment, page 450). For real sepsis, pro- 
fuse haemorrhages from the mucous membrane, gangrenous diphtheri- 
tis, and ecchymosis of the cutis, the utmost tonic and stimulating 
measures, with large doses of wine, quinine, musk, and naphtha, must 
be employed. Washing the body with chlorine-water has also 
been recommended. I cannot, however, conceal the fact that, in real 
septic cases, all these methods of treatment have always failed me. 

Pulmonary tuberculosis, which comparatively often develops 
after measles, may stop, like that originating spontaneously. Large 
doses of quinine — from two to four grains given at one time every 
other day — exercise a favorable influence upon its course. A year's 
constant use of cod-liver oil strengthens the nutrition, and perhaps, 
also, guards the organism against new tuberculous attacks. Coun- 
try air, sea-baths, and a rational inuring, are the best prophylactics 
against the progress of tuberculous affections. 

(3.) RuBEOLJE {Rotheln). — There is scarcely another disease upon 
which the views of authors differ so vastly as upon rubeola. Some 
look upon it as a modified scarlatina, others as measles, and still others 
as an amalgamation of both. Erythema, urticaria, even typhous and 
cholera exanthema, have been described as rubeola ; and the confu- 
sion finally became so inextricable that later writers have denied the 
existence of the disease entirely, and ascribed all obscure and doubt- 
ful cases to some of the above-mentioned affections. This later view 
I also entertained till the spring of 1865, when I became better in- 
formed. At that time eleven persons — three adults and eight chil- 
dren, from six months to eight years of age — came under my care. 
Without any distinct prodromata presented, they all had an eruption 
of exanthema, which differed in no respect from that of measles. My 
friend Lindicurm at the same time had five additional cases to treat, 
and, upon inquiries, several physicians in Munich recollected having 
seen at that time a peculiar fever, " a febrile urticaria with a measles- 
like exanthema." Neither before nor since that time have I met with 



ERUPTIVE FEVERS. 429 

this eruption. It is proper to remark that this disease was not imme- 
diately preceded nor soon followed by any epidemics of measles or 
scarlet fever. The phenomena presented by this affection are sketched 
by Kostlin, of Stuttgart, in the following manner : In the winter of 
1860-'61 an extensive epidemic of rubeola prevailed in that city dur- 
ing five or six months. The exanthema was not smooth, but slight- 
ly papulous, had a yellowish tint, not confluent, but formed short 
or long, serpentine, seldom straight lines, which, in most instances, 
covered the entire body. The exanthema was not infrequently ac- 
companied by considerable itching of the skin. The eruption, as a 
rule, disappeared in two or three days, sometimes even sooner. In 
most instances it appeared and ran its course without the least catar- 
rhal symptoms, and without fever. Though- mild, this exanthema 
was extremely infectious, infecting whole families. Several children 
were even twice attacked during the same epidemic. It appeared 
at the same time in various other cities and towns in Wiirtemberg. 
Lately twenty-three additional typical cases of rubeolas were ob- 
served and described by 0. Oesterreich; and Mettenhehn, in Schwe- 
rin, also observed an epidemic of rubeolse in the summer of 1879, 
whose description tallies with those already given of this exanthe- 
mata by other writers. 

Symptoms. — The symptoms which I have observed may be com- 
prised in a few words. The exanthema differs in no respect from 
that of morbilli; small round spots of the size of lentils cover the entire 
body, occasioning, in most instances, a considerable amount of itching. 
At some places these spots stand so closely together that they coalesce 
and form irregular figures. They also rise somewhat above the level of 
the normal integument, and the finger, in lightly passing over them, 
perceives an unequal hardness. The eruption differs, however, very 
much from measles in respect to its duration. It completely disap- 
pears by the end of the first, or, at the longest, by the end of the sec- 
ond day, and the desquamation that succeeds it is very insignificant, 
barely noticeable. The same is true of the catarrhal symptoms. Al- 
though, along with an intense eruption of the exanthema on the face, 
the eyelids swell up, and the conjunctivae are somewhat injected, 
still bronchial catarrh is uniformly absent, which, in morbilli, on the 
contrary, is a pathognomonic, never-failing symptom. Scarcely any 
precursory stage was noticeable in most of our cases, and the indis- 
tinct febrile phenomena disappeared so completely after the first 
day, with the fading of the exanthema which soon followed, that by 
the third day it was totally impossible to keep the children in bed, 
and they quickly recovered without the first sequela. 

Treatment. — This is purely expectant. Internally, dilute acids, 
and, externally, cold ablutions, to relieve the intolerable itching of 



430 DISEASES OF CHILDREN. 

the skin, were the only remedial means employed in this most harm- 
less of all acute febrile exanthemata. 

(4.) Variola, Small-pox. — Genuine human small-pox is the most 
positively declared of all acute exanthemata. It, however, occurs com- 
paratively rarely, on account of the compulsory vaccination that is in 
force at present in almost all civilized countries, and in time will 
probably be totally supplanted by the milder forms of variolois, also 
called variola modificata, and by varicella. 

By variola is understood a febrile, contagious, pustular, eruptive dis- 
ease, whose course is uniform. It may be divided into several periods. 

Symptoms. — Three distinct stages are distinguished. (1.) The 
stage of incubation and of prodromorum ; (2), that of florescence of 
the exanthema; and (3), that of desiccation. 

(1.) Stadium Incubationis et Prodromorum. — The period from 
the reception of the contagion to the eruption of the exanthema fluc- 
tuates between eight and foui-teen days. The first few days of this 
period usually pass without any signs manifesting themselves; but 
in the last three days ])receding the eruption severe symptoms are 
observed. I shall limit myself here to a delineation of the prodromata, 
as they occur in a child under one year, taking it for granted that a 
knowledge of the course of small-pox in adults has already been ac- 
quired from other sources. Small-pox now occurs only in very young 
children, for vaccinated persons are totally exempt from it, and by us, 
in Germany, vaccination is usually performed before the end of the 
first year. 

If they have been infected a few days previously with genuine or 
modified variola poison, we observe slight gastric symptoms, such as 
loss of appetite, coated tongue, vomiting, and constipation. There 
will also be observed excitement of the vascular and nervous system, 
hot skin, frequent pulse, great restlessness alternating with stupor, 
starting up from sleep with an outcry, gnashing of the teeth, convul- 
sions, and occasionally syncope, with rapid collapses. All these symp- 
toms, which certainly have nothing characteristic about them — for the 
subjective pain in the back and loins, so constant and marked a symp- 
tom in adults, is not available in infants who do not speak — become 
aggravated throughout the next three days, regular exacerbations 
come on toward the evening, till, finally, the exanthema breaks out. 

(3.) Stadium Eruptlonis et Florescentlm. — The first signs of the 
eruption are seen on the face ; thence it spreads upon the trunk, and 
the upper, and lastly upon the lower extremities. The eruption is 
completed in from twenty-four to forty-eight hours. 

The small-pox pustule has the following history, viz. : a red, 
slightly-elevated spot is first perceptible upon the skin, differing in no 



ERUPTIVE FEVERS. 4,31 

respect from the exanthema of measles. In the centre oi tnis red 
spot a small tubercle develops, and upon this tubercle a still smaller 
vesicle appears, which enlarges very rapidly, so that on the second day 
it has reached the size of a pin's head ; on the third, that of a lentil ; 
and finally, the primary red point is transformed into a tense, little 
blister, of the size of a split pea, with a central depression. 

These originally red points do not all go through this metamor- 
phosis ; a great many of them never become vesicles, but disappear 
entirely in a few days, especially those on the lower extremities. On 
the feet, in particular, the eruption is feebler than on any other part 
of the body. 

The course of variola, as regards the form and duration of the ex- 
anthema, is precisely the same in children as in adults. 

When the exanthema is not excessively diffused over the whole 
body, the general symptoms will subside materially after it has made 
its appearance. The great restlessness and delirium vanish, the pulse 
becomes slower and softer, the breathing more regular, but the 
specific variola odor is more marked after the eruption than before. 
Where the eruption on the mucous membrane of the eyes, nose, 
mouth, etc., is very abundant, no mitigation in the vascular and ner- 
vous excitement will be noticeable, for the severe pain induced by the 
process prevents the patients from becoming tranquil. 

On the sixth day after the eruption, or on the ninth from the in- 
vasion, the suppurative fever — febris secundaria — appears also in chil- 
dren. The inflammatory areola around the vesicles become enlarged, 
the face swells so as to totally disfigure the patient, the skin again 
becomes hot, and such an intolerable itching supervenes that the 
child will scratch open the pustules, notwithstanding all the precau- 
tions that may be taken to prevent it. Thus it finally comes to the — 

(3.) Stadium Exsiccatioiiis. — It does not begin at once on the 
whole body ; the pustules burst and dry up in the same order in 
which they appeared : thus, first on the face, next on the neck, on 
the wrists, on the trunk, and lastly on the lower extremities. Every 
pustule is nearly dried up by the ninth day after its appearance, or, 
if we include the two or three days of the prodromatory stage, on 
the eleventh or twelfth day of the disease all the pustules will have 
commenced to desiccate. Spontaneous bursting, or simple drying up 
without bursting of the pustules, hardly ever takes place in small 
children, for they cannot refrain from palliating the terrible itching 
by scratching or rubbing. 

Thus bi-own thick crusts form upon the whole body, especially on 
the face. If left to themselves, these crusts will fall off in from four 
to five days, and leave behind a cicatrix covered with new epidermis, 



432 DISEASES OF CHILDREN. 

which the patients frequently scratch off. Small-pox cicatrices have 
the same formation in children as in adults ; but, as the cutis in the 
former is more delicate and thiner, the destruction is therefore more 
conspicuous, and the inequalities, which at first appeared very marked, 
become less unequal in the course of years. 

During this period the pustules in the mouth become converted 
into flat superficial ulcers, and induce an augmented mucus and sali- 
vary secretion. The secondary fever disappears with the desiccation, 
the appetite returns, and the recovery progresses rapidly. Occasion- 
ally the nails are cast off". 

Tlie prognosis, in children under one year of age, is extremely 
unfavorable, for nearly sixty per cent, perish. 

The principal danger to small children is, (1), from a violent pro- 
dromatory stage, where pr6found stupor or convulsions endanger life ; 
and (2), from the secondary fever, which may assume a typhous or 
septic character. 

The quantitative and qualitative variations are the same as in 
advilts. Here also we have variolse discretas, cohaerentes, corymbosoe, 
and confluentes ; in qualitative regard, variolae crystallinise, siliquosae, 
depressfe, cruentae, gangrsenosie, etc. 

The most frequent complications are : laryngitis, pleurisy, menin- 
gitis, intestinal catarrh, serious diseases of the eye, which frequently 
lead to phthisis bulbi, otorrhoea, and gangrene of the scrotum. 

The most frequent sequels deserving to be mentioned are : furun- 
culosis, abscesses of the cellular tissue, pyaemia, inflammations of the 
joints, necrosis of the bones, and, what is very remarkable in small 
children, scrofula in all its forms and localizations. The mortality in 
consequence of small-pox, in children under one year of age, is very 
great, for, as has been stated, barely forty per cent, recover. 

Etiology. — Small-pox is contagious to a high degree, and, in fact, 
also infectious through the atmosphere, is communicated by contact 
and by inoculation. It is most infectious during the suppurative and 
desiccating stages. But the most important point in practice is that 
genuine small-pox generates small-pox in not only the xmvaccinated 
children, hut that occasionally the mere contact with varioloid^ and 
even with very mild varicella^ may produce the genuine human 
variola in an unvaccinated child. 

Treatment.* — A prophylactic treatment is spoken of in many dis- 

*[As small-pox, unfortunately, is not so rarely met with in this country as it ap- 
pears to be where the author has made his observations, we deem it proper to append 
some remarks in regard to its pathology and treatment. At the post-mortem exami- 
nation of small-pox, there will generally be found congestion and infiltration of the 
mucous membrane of the alimentary canal and some of the internal organs, especially 



ERUPTIVE FEVERS. 4,33 

eases, but in none can one be relied upon witli so mucli certainty, and 
accomplislied by such a simple, banxiless procedure, as in variola. It 
is inoculation with the small-pox lymph from the cow, or 

VACCINATION. 

An eruption of pustules occurs in our domestic animals, and the 
pocks on the udder, in particular, have been known for a long time. 
Whether these always originate through contagion, or spontaneously, 
is not yet satisfactorily decided; their course, however, has been 
accurately observed. Canstatt reports as follows concerning it : 

A few days before the eruption the cows eat less, give less milk, 
and the udder has an increased temperature. Soon after this, small 
reddish tubercles appear, especially on the external surfaces of the 
teats, which become converted into umbilicated pustules, and between 
the fourth and seventh day these have attained to complete maturity. 
The pustules have a pearly color, at first are filled with clear lymph, 
which subsequently becomes purulent, and they are surrounded by red 
areolse. Touching the udder causes the animal marked pain. The 
pustules desiccate by the twelfth or fourteenth day, fall off, and leave 
circular cicatrices. 

It was known for more than a hundred years that those who had to 

the brain and lungs. The serous coat of the blood-vessels seems turgid and of a 
blood-red color. The pustules are found scattered over the mouth, pharynx, oesoph- 
agus, and rectum, particularly if the patient have succumbed during the suppurative 
stage. Occasionally they are seen in the larynx, trachea, and bronchi, and the urinary 
bladder. Where they have ruptured, the mucous membrane will be found covered 
with an adventitious membrane. Each well-formed pustule, when carefully dissected, 
will be seen to consist of two compartments, the upper one being the larger. These 
compa,rtments are both filled with pus, and communicate with each other at the 
marginal borders. This septum is a layer of false membrane, deposited in the derma 
at an early stage of the disease, which, by removing the surface-layer of the pustule, 
is brought into view, presenting a bright-red or purple color, and is highly infecting. 
But the mature pustule is multilocular, and, when a transverse section is made, pre- 
sents an appearance that has been compared to a severed orange. 

The urinary secretion in variola undergoes certain changes corresponding with the 
gradations of the disease. During the eruptive fever the quantity is lessened, its spe- 
cific gravity increased, its color deep red and turbid, and it sometimes contains traces 
of albumen. Becquerel states that, " in five cases with severe symptoms during the 
eruptive stage, the quantity of urine was diminished, amounting on an average to only 
twenty-three and a half ounces in twenty-four hours. There was no increase in the 
specific gravity, it being only 102U.6. It frequently precipitated uric acid, either 
spontaneously or by adding nitric acid, and in one case only was a trace of albumen 
discovered." During the suppurative stage " the urine retained the synochal char- 
acter so long as the symptoms continued, remaining unaltered, and, in the cases in 
which the fever persisted, till fatal termination. Sediments containing muco-pus also 
appeared in it." During the period of desquamation, " it is cither normal or limpid " 



434 DISEASES OF CHILDREX. 

feed or milk such cows would become infected, and it also became a 
notorious fact that these persons remained exempt from the genuine 
small-pox. But the first accurate test and experimental confirmation of 
this fact was not instituted till the 14th of May, 1796, when Jenner^ 
for the first time, inoculated a child eight years of age with the matter 
taken from the hands of a milker. The counter-test was instituted in 
this child on the first day of July following, by inoculating it with gen- 
nine variola poison. The child remained unaffected. This experiment 
was subsequently repeatedly performed, and the first public vaccinat- 
ing institution was established in London as early as 1799. Since that 
time this sanitary measure has spread and become renowned through- 
out the civilized world, and there is hardly a country now where 
vaccination in the first year of life is not prescribed by law. 

Vaccination is best performed in the following manner : first of all, 
it should be stated that the child from which the matter is to be taken 
must be perfectly developed, entirely free from cutaneous eruptions, 
and free from febrile diseases. If it has been vaccinated eight days 
previously, it will now present several perfectly legitimate vaccine 
pustules. One of these is punctm-ed with the vaccinating needle, 
held obliquely in such a manner that pure lymph only, unmixed with 

while, in the putrid form, "it appears decomposed, ammoniacal, and not unfrequently 
of a dark-red color, from the presence of hsematine." 

The treatment of simple variola, when uncomplicated by any other disease, is aa 
thoroughly expectant as the treatment of any other exanthema. Confinement to bed, 
cooling regimen, diluents, sponging the skin with tepid water, and the occasional use 
of a saline purgative, is all that is necessary. When the secondary fever sets in, 
febrifuge salines, such as potass, citras, or liq. ammo, acetas, or the effervescing 
salines, may be given. Sleeplessness may be relieved by opium, and, when the vital 
powers begin to fail, stimulants and a generous diet are indicated. Where the cere- 
bral symptoms are severe, leeches, according to the age of the child, may be applied 
behind the ear, and mustard-draughts to the feet. Mineral acids are useful in cases 
which are complicated with haemorrhages, and, if conjunctivitis exists, emollient poul- 
tices to the eyelids may greatly relieve it. If the eruption is tardy, a warm bath and 
sudorifics may hasten its appearance. During the secondary fever, small doses of 
opium will be found very serviceable, but this is contraindicated in the primary one, on 
account of the extreme excitability of the nervous system. In the graver forms, where 
the vital organs have been attacked, a more energetic treatment must be employed. If 
the disease has assumed an unfavorable type, from the very first, or the nervous 
symptoms are of a severe character, stimulants and tonics, with a nutritious diet, 
will have to be liberally administered. Symptoms indicative of serious internal con- 
gestion are best combated with dry cups and counter-irritation. Abstractions of blood, 
even topically, as a rule, are inadmissible in small-pox, particularly in the confluent 
variety, when the full quota of strength will be required to withstand the great drain 
upon the system from the extensive suppurating surface. Headache and delirium 
are best relieved by the application of ice to the head, or cold-water affusions repeated 
every two or three hours.] 



ERUPTIVE FEVERS. 435 

blood, will escape. One or two minutes are always required before a 
large drop appears, for the reason that vaccine pustules,* as is well 
known, are not simple, but multilocular vesicles. After the needle 
has been wiped perfectly dry, it is dipped in this lymph in such a 
manner that its anterior and dorsal surfaces are moistened by it. The 
arm of the child to be vaccinated is grasped below the shoulder, the 
integument on the outer surface of the upper third is made properly 
tense, and the point of the needle is made to pierce the skin four or 
five times. The punctures ought not to bleed, and the vaccination 
succeeds best when a minute red dot only is seen afterward. The 
punctures should be at a distance of at least six lines from each other, 
for otherwise the pustules that are subsequently to appear w^ll coalesce. 

The summer is the most proper time of the year to vaccinate, 
because in winter the pustules have been observed to develop 
very slowly. The best age is between three and twelve months. Still, 
when epidemics of small-pox prevail, infants may be vaccinated a few 
days after birth. Those children about to be vaccinated must be per- 
fectly well, and free from any of the troubles of dentition (vide p. 106). 

Vaccinated children require no special treatment. They may be 
washed and bathed afterward as well as before, and, from the fourth to 
the tenth day, the arm may be wrapped up in a fine piece of linen, 
merely to prevent friction. The erythema surrounding the pustviles 
is thereby also kept within proper bounds. 

The transmission of the cachexias from one child to another by 
vaccination has only been proven in regard to syphilis. Scrofula and 
rachitis cannot be transmitted by vaccination ; but, since the most cor- 
rect views do not always prevail among the public in regard to this 
point, and in order to avoid all future reproach, it is best to take the 
matter from healthy children only, and who are entirely free from 
cutaneous diseases. 

It is well to take the precaution to have vaccine lymph constantly 
on hand, in order that, in case an epidemic breaks out, it should not 
first have to be looked for or ordered. It is collected without any 
difficulty or trouble in the following manner : one or several well-de- 
veloped eight-day vaccine vesicles of a healthy child are punctured 
several times, and a few minutes allowed for the escape of the drop. 
It will then have become tolerably large, when an ordinary glass capil- 
lary tube held slightly oblique with its end in the drop of lymph, may 
be charged. The capillary tube must be held parallel with the arm for 
this reason, that, in case the child should stir or become restless, it will 
not be injured by it. I remember once to have had a child under 

* [European authors generally use the word pustule for the vesicular stage of vao 
cinia.] 



436 DISEASES OF CHILDREN. 

treatment, in whom the glass tube was broken in consequence of the 
clumsy manner in which it was applied, the glass fragments were forced 
into the pustules, and a malignant erysipelas of the whole arm was the 
-esult. The little tube, according to the laws of capillary attraction, 
soon becomes filled with lymph, and may be withdrawn and cut off with 
the scissors, leaving about one-eighth or one-fourth of an inch unfilled 
at both ends, which are then closed with sealing-wax. In this manner 
vaccine lymph may be preserved in a fluid form for years. 

When the lymph thus preserved is about to be used for vaccination, 
the two closed ends should be cut off Avith the scissors, the capillary tube 
is thrust into another somewhat larger glass tube, both are held be- 
tween the thumb and index-finger, and the vaccine matter is blown 
directly upon the lancet. The vaccination is thereafter carried on as 
in the ordinary way, from arm to arm. 

The vaccine pustule develops in the following manner : the small 
punctures may be seen for a few hours as minute dots. If no bleeding 
at all has taken place, all traces of the puncture will disappear, but, if 
that was the case, a few dark-brown spots will be visible for some 
time. On the third day after the vaccination, the vaccinated spot be- 
comes markedly red, and a small, round, hard tubercle arises, upon the 
apex of which a pearl-like vesicle becomes developed by the fifth day. 
This vesicle daily grows in breadth, becomes distinctly umbilicated, 
like a variola pustule, and by the eighth day has reached the acme of 
florescence, when it will be seen as a bluish-red translucent pustule, 
surrounded by a red areola. 

The pustules are constructed in compartments ; their contents be- 
gin to turn turbid on the ninth day, the red areola enlarges more and 
more, the induration increases, the glands in the axilla become sensi- 
tive, and general symptoms supervene. The children become very 
restless, do not sleep at night, have a hot skin, great thirst, and are 
very much disposed to acute diseases, especially pneumonia and intes- 
tinal catarrhs. These general phenomena disappear in two or three 
da3'S. From the eleventh day on, the red areola fades, and the opaque 
pustule aciuninates and loses its central depression. When properly 
protected, it will not burst, but dry up into a brown crust, which falls off 
in two or three weeks, and leaves behind a white, depressed, somewhat 
irregular cicatrix, which, if scratched, will suppurate for a few hours, 
and then likewise dry up into a large crust with irregular contours. 

The course of vaccination is not always so regular and simple as 
it has been sketched above. The secondary fever sometimes becomes 
so intense that life seems to be in danger. The children are attacked 
by severe convulsions, become collapsed, look very pale, or vomit, con- 
tinuously, at first white, then bilious gastric mucus. No instance, how- 



ERUPTIVE FEVERS. 437 

ever, nas been heara of where the secondary fever brought about a fatal 
termination ; and, when children with vaccine pustules die, some other 
remote cause of death will be found on careful post-mortem examination. 

In children with a fine, irritable skin, other parts of the integu- 
ment become affected ; a nettle-rash or a varicella-like eruption of vesi- 
cles occurs on the whole or some part of the body. Scrofulous chil- 
dren are attacked by an extensive pustular eruption, in which the 
vaccinated arm especially participates, and then the vaccine pustules 
will not heal at all, but degenerate into scrofulous ulcers. 

Erysipelatous inflammation of the arm is one of the worst compli- 
cations which, through rough treatment of the pustules, particularly 
in cachectic persons, may develop between the ninth and twelfth day. 
The erysipelas spreads over the entire arm, even over a part of the 
trunk, the fever is intense, recovery progresses but yery slowly, and 
the pustules ulcerate. 

A too rapid and a too slow formation of pustules may be mentioned 
under the head of anomalies of the local course. If the vaccine lymph 
was poor, obtained from an imperfectly-developed pustule, small vesi- 
cles will form as early as the second or third day, will be but little 
umbilicated, barely attain to the size of a lentil, and dry up in six or 
eight days. On the other hand, as a rare anomaly, instances are re- 
lated in which the eruption has been materially retarded, and the pe- 
riod of incubation was eight to ten days, I cannot remember to have 
observed a single instance of this kind in the many hundreds of cases 
that I have had the opportunity of vaccinating. 

As a real sequela of a vaccination which has been performed with 
all due caution, the sudden breaking out of scrofulous affections only 
need be mentioned. This occurs in children the progeny of tubercu- 
lous parents, and they are often attacked with remarkable rapidity 
and vehemence. 

The question. How long a time does vaccination serve as a protec- 
tion against variola ? has been considerably ventilated, and the inves- 
tigations that have been instituted for the purpose of solving this 
question have finally led to the general estabhshment of a revaccina- 
tion at the time of puberty. Whether it is assumed that vaccination 
protects for life, or only for ten or twenty years, it is, at least, certain 
that children who have had proper vaccine pustules are totally pro- 
tected against genuine variola. Hence vaccination is to be looked 
upon as a great blessing to humanity, in which light also the Parlia- 
ment of England regarded it, and, in gratitude to its discoverer, voted 
him a national gift of thirty thousand pounds sterling. 

If the genuine or modified small-pox breaks out in a family in 
which one child is not yet vaccinated, this child should be vaccinated 
29 



43S DISEASES OF CHILDREX. 

as quickly as possible, so as to mitigate the course of the exanthema, 
which usually breaks out notwithstanding. The vaccine and small 
pox pustules then run an undisturbed course together. Still, it haa 
been observed that, when vaccinia anticipates the general cjcanthema, 
the latter assumes a less dangerous character. 

The treatment of small-pox is to be conducted in as expectant a 
manner as scarlet fever and measles, being directed to the symptoms 
as they occur. The ventilation of the room should be carefully 
looked after, the temperature should be 58° F., and all weakening 
measures, such as abstraction of blood, calomel, and cathartics, must 
be absolutely avoided. When intestinal catarrh is present, as is usu- 
ally the case in children under one year of age, it need not be inter- 
fered with so long as it is moderate, as the cerebral symptoms are 
thereby visibly mitigated ; but, so soon as it threatens to become pro- 
fuse, an attempt is to be made to control it by small doses of opium, 
one drop of the tincture every three or four hours. 

With the hreaking out of the pocks, the indication is to prevent the 
development of the pustules in the face, and Avith it the formation of 
cicatrices, which so frightfully disfigure the patient. All the reme- 
dies recommended for that purpose are sadly deficient in many re- 
spects, and perceptible cicatrices result, notwithstanding all manner 
of treatment. An early cauterization of the pustules, which, accord- 
ing to Sretonneaii, is performed by dipping a pointed gold needle in 
a concentrated solution of nitrate of silver, and then puncturing with 
it every young pustule, is the surest remedy. 

K the pustules are thus cauterized on the second day of the erup- 
tion, they will be arrested in their development ; and the integument 
in a few days becomes elevated by a thin crust, and, after it has fallen 
off, no deforming cicatrices will be perceptible. 

But this cauterization is painful, and, in confluent small-pox, re- 
quires much time, owing to which this treatment has been limited to 
the eyes, eyelids, and nose, while the other parts of the face, the fore- 
head, cheeks, and chin, are covered with mercurial plaster. It must 
be changed ever}' other day, and should be discarded altogether if the 
pustules have become developed notwithstanding. One portion of 
the pustules, no doubt, is arrested and destroyed by this treatment ; 
another does not attain to a proper, extensive development, and very 
few only leave permanent, disfiguring cicatrices. 

Lotions of corrosive sublimate, chlorine-water, and painting the 
face with iodine, have also been recommended.* The general man- 

* [Prof. J. Hughes Bennett recommends the following mixture : carbonate of zinc, 
three parts ; oxide of zinc, one part, rubbed in a mortar with olive-oil to a proper 
consistence. — A solution of gutta-percha in chloroform is equally as efficacious as the 



ERUPTIVE FEVERS. 439 

agement after the eruption is limited to an antiphlogistic diet, to 
keeping the bowels open, and, when the restlessness is very great, to 
the administration of small doses of opium. 

The utmost attention will be required during the periods of suppu- 
ration and desiccation, to prevent the patients from scratching them- 
selves and prematurely tearing off the crusts. Linen mittens, secured 
at the wrists, will be found to be of great benefit. Starch, powder, or 
a liniment of lime-water and olive-oil, is very efficacious in assuaging 
the itching of the skin. The patients should not leave the room till the 
crusts have fallen off, and the new cicatrized skin begins to turn white. 

If the fever has assumed a torpid, septic character, nervines and 
tonics should be plentifully administered, such as have already been 
described in detail in the therapeutics of scarlet fever. 

(5.) Modified Small-pox, Varioloid and Varicella, Chickeic- 
POX. — Both physicians and the public had been familiar with a mild 
form of children's disease, known by the names of varicella and 
chicken-pox, long before vaccination was discovered. But there is a 
long list of gradations between this lowest step of development of 
small-pox and the most perfect form of confluent variola, all of which 
have been comprised under the name of varioloid, or modified small' 
pox. To regard them as exanthemata capable of existing by themselves, 
without any direct connection with genuine sraall-pox, is not very 
proper, for the simple reason that it has often happened that unvacci- 
nated patients, with mild varicella, were attacked by the severest 
forms of small-pox ; and, conversely, that vaccinated persons, through 
contact with patients having genuine small-pox, acquired only vari- 
cella. 

Nevertheless, it is advisable, in order more easily to comprehend 
these affections, to retain the old denominations. Both of these cer- 
tainly not very distinctly -de fined forms of disease, varioloid and vari- 
cella, will therefore here be separately considered. 

Symptoms of Varioloid. — The same stages may be observed in 
varioloid as in variola, but they are all of shorter duration, and less 
sharply defined. The entire duration of variola, from the invasion of the 
prodromata until the desiccation of the pustules, embraces a period of 
from sixteen to eighteen days, that of varioloid from seven to eleven days. 

The prodromata are the same as in variola, but usually do not last 
three full days, twenty-four to thirty-six hours at the most, and are 
less intense in general. The specific smell of small-pox is totally ab- 
sent in varioloid ; on the other hand, a dark-red, large-spotted erythe- 
ma of the integument, which has been described by the name of 

preceding remedy. And, of late, carbolic acid has also been recommeuded for the 
same purpose.] 



4,40 DISEASES OF CHILDREN. 

"rash," supervenes, a sign not usually seen in variola, lliis erythema 
is not to be regarded as the commencement of the pustular eruption, 
for the pustules that subsequently develop may appear upon the parts 
of the body which the rash has not invaded. 

The exanthema breaks out more rapidly and less uniformly. The 
eruption does not begin on the face alone, nor does it descend gradu- 
ally upon the trunk and the lower extremities, but appears almost 
simultaneously upon the whole body. Whereas, in variola, all the 
pustules on one part of the body are at an equal stage of develop- 
ment, and no new accessions are noticeable ; while, on the contrary, in 
varioloid tubercles, vesicles and large pustules are usually found along- 
side of each other, and the number of the pustules increases for sev- 
eral days. While it is true that solitary pustules, which, in regard to 
form and structure, differ in no way from those of genuine small-pox, 
occur in varioloid, the majority of them, however, do not become um- 
bilicated pustules, but remain hyaline vesicles of the size of hemp- 
seed, and desiccate into correspondingly thin scabs. 

The general symptoms, which were very slight from the com- 
mencement, either disappear entirely wuth the eruption of the exan- 
thema, or are, at least, reduced to a minimum. No real secondary fever 
occurs in this disease, and the patients, in most instances, feel so well 
that they can hardly be kept in bed. Even the most developed pus- 
tules begin to dry up by the fifth or sixth day at the latest, and occa- 
sionally a few solitary followers are observed in the midst of the dry- 
ing ones, but they only become vesicles, and usually, as such, soon 
perish. The suppuration of the pustules never becomes so intense as 
to produce an erysipelatous redness around them, and but few of them 
ever burst. They usually dry up quickly, the crusts fall off in a few 
days, and leave behind them slightly-red, barely-depressed cicatrices. 
The pustules on the mucous membrane of the mouth and pharynx 
heal in an equally short time. 

Seqiielm are rare in varioloid, and attended by little danger in pre- 
\-iously healthy children. Occasionally an obstinate furunculosis, or a 
profusely suppurating impetigo, follows. The latter is generally at- 
tended by swelling of the adjacent lymphatic glands. In most scrofu- 
lous children the various cachectic affections make very rapid progress. 

The prognosis is more favorable than in variola, for, of children 
imder one year, only eight to ten per cent., and of older ones from 
five to six per cent., perish. 

The danger especially to be apprehended is from a participation of 
the larynx, through which croup-symptoms and sudden oedema of the 
glottis are occasioned. Convulsions which have a tendency to a rapid 
fatal termination, comphcation Muth pneumonia or meningitis, and 



ERUPTIVE FEVERS. 44X 

finally a septic cnaracter of the fever that exceptionally becomes de 
veloped, are among the recognized sequelae. 

Treatment. — Vaccination offers no protection against varioloid, as 
it only modifies the contagion of genuine small-pox to such an extent 
that, when communicated to a vaccinated child, it at most produces 
varioloid. But, since it has often been observed that varioloid runs a 
milder course in a vaccinated child than in one that is not vaccinated, 
vaccination must therefore, in this respect, also be looked upon as a 
beneficial prophylactic. 

The treatment of the disease that has already broken out is purely 
expectant. Every thing that has been said with respect to variola is 
apphcable to varioloid. No cauterization of the pustules on the face 
is necessary in this case, for the pustules penetrate less deeply into the 
cutis, and only leave superficial pittings. Disfiguring cicatrices of the 
face, as a rule, may be readily prevented by the aid of mercurial plaster. 

In the early stage of the disease it is best to give some diluted 
mineral acid ; if diarrhoea be present, mucilaginous remedies. In laryn- 
geal croup, the greatest benefit is derived from intense cauterizations 
of the pharynx, larynx and epiglottis, with a concentrated solution of 
nitrate of silver ( 3 ss to water | j). These cauterizations are easily 
performed ; but, in order to be convinced that the contents of the cau- 
terizing sponge find their way into the larynx, the index-finger of the 
left-hand should first be thrust quickly far into the mouth of the child, 
the epiglottis raised up, and the sponge then rapidly ^Dressed into the 
glottis. The head of the child should be held firmly and steadily by 
an- assistant. This procedure always requires a certain amount of 
dexterity and practice. In children who have teeth, it is advisable to 
protect the last joint of the index-finger with some lint, before it is 
introduced into the mouth, for they are very apt to bite it severely. 

In small children, the immoderate amount of scratching during 
the desiccating stage may be prevented by the aid of linen mittens ; 
older children, naturally, are much offended and annoyed by this pro- 
cedure. In the latter, the nails, at least, should be cut off as short 
as possible. 

Convalescence usually progresses rapidly, and a special tonic after- 
treatment will but very seldom be required. 

Symptoms of Varicella. — Varicella, also called false, chicken, water, 
swine, or stone pox, is the least dangerous, the most insignificant of 
all exanthematous affections, and the majority of cases, especially 
during the prevalence of an epidemic, do not come at all under medi- 
cal supervision. 

Hardly any precursory signs are observed in large and other- 
wise healthy children. Occasionally slight gastric symptoms, vomit- 



442 DISEASES OF CHILDREN. 

ing, loss of appetite, stomacli-aclie, mild febrile phenomena, and 
uriiiaiy difficulties, precede the eruption of the exanthema for one, 
at the most two days. 

The exanthema, without any particular aggravation of these pro- 
dromatory symptoms, now breaks out simultaneously upon different 
parts of the body without any apparent order. In from six to twelve 
hours small red spots grow into vesicles of the size of lentils or peas, 
which, regarded by themselves, cannot be distinguished from small 
blisters produced by a burn. Most of them are circular, or slightly 
oval and unilocular, and when punctured the entire contents escape 
at once. They are not at all, or but slightly, umbilicated. The ma- 
jority of these vesicles are found upon the back and breast, a few 
upon the extremities, and the least upon the face, one or two pus- 
tules only appearing on the forehead. 

Usually it is not completed by one eruption, but a second crop of 
vesicles appears on the next day, and then we have fresh and totally- 
dried varicella vesicles alonsrside of each other. Althousrh most of 
the vesicles are not larger than a lentil, several pustules are found in 
all varicella patients, upon the forehead or back, which are slightly 
anibilicated, and resemble the genuine variola pustule. 

The course of most of the vesicles is very rapid. Their contents 
become turbid as early as the second or third day, and dry up on the 
fourth ; flat, bloody crusts then form, which fall off in a few daj's, and 
leave no pitting, but a red spot. The narrow red areolae which formed 
at the time the vesicles became opaque, disappear as soon as the crusts 
have desiccated. 

The red spot, which for several weeks indicates the former site of 
the crust, is not to be seen after this time. 

Unless accessions of vesicles particularly protract the coiirse, the 
whole disease, with the exception of the red spots just mentioned, 
marking the site of the pustules, is entirely completed in from eight 
to ten days. These red spots will remain for some time thereafter. 
No sequelcB are observed in this affection, but, in scrofulous children, 
chronic suppurating eruptions sometimes develop directly from the 
vesicles and resist for a long time the desiccatina: treatment. Vari- 
cella regularly terminates in rapid recovery. 

The variations of ordinary chicken-pox described in medical litera- 
ture are : varicellas lenticulares, where none of the vesicles are larger 
than lentils, and not umbilicated ; and varicellas coniformes, or acu- 
minatae, the so-called horn-pox, where hard tubercles form at first upon 
the skin, on which small acuminated vesicles originate the next day. 
The vesicle dries very quickly, and its indurated base shrinks by re- 
peated desquamations. 



ERUPTIVE FEVERS. 443 

If we are to recapitulate the essential differences between vario- 
loid and varicella, we will find that varicella, in contradistinction to 
the former, has but a short or no precursory stage, that the exan- 
thema appears in a perfectly orderless manner, and is followed by 
many accessions, the face being almost wholly spared ; that it dries 
up in two or three days and leaves no pitting. No danger to life, 
nor any permanent injury, is to be apprehended from varicella. 
Vaccination and genuine small-pox do not serve as protection against 
varicella. 

Treatment of Varicella. — If an expectant treatment has been pro- 
nounced sufficient for varioloid, it is of course still more so for vari- 
cella. When the children are free from fever, as is usually the case, 
it is a difficult task to put them in bed. Nor is it absolutely neces- 
sary to keep varicella patients in bed, for no bad effects are usually 
seen, even when they are allowed the utmost freedom, and expose 
themselves to great changes of the temperature. 

Where febrile prodromatory symptoms are present, some mild 
laxative, such as tamarinds or neutral salts, may be prescribed. The 
pustules should be pencilled over with a little oil or cocoa-butter ; 
the patients are, for a few days, put upon a bland vegetable diet, 
and kept in a room of uniform temperature. The disturbed activ- 
ity of the skin is remedied by three or four lukewarm-water baths 
after the crusts have fallen off. 

(6.) Eetsipelas. — In children of from five to fifteen years, ery- 
sipelas, which differs in no respect from that of the adult, occurs, 
and it consequently deserves no further consideration here. But 
erysipelas of the new-born child and nursling presents such impor- 
tant modifications, especially symptomatically and prognostically, 
that it seems to call for an especial description. 

This kind of erysipelas is distinguished by a great and constant 
disposition to migrate, not limiting itself to any small or large por- 
tion of the body, but creeping over the entire surface of the skin. 
Adjacent parts are constantly attacked, while those previously af- 
fected fade gradually, and the disease is not arrested until the whole 
surface of the body has been implicated. In exceptional cases the 
pernicious process is not content with even this, but begins anew, 
at some place, and again wanders over a greater or less portion of 
the body. 

The local symptoms do not differ from ordinary erysipelas — red- 
ness, swelling, warmth, and pain on pressure. The exanthema re- 
mains in its florescence from one to three days, and fades remarkably 
quickly as soon as it has attacked new parts. 

The whole course, in the rare cases of recovery, lasts from four 



444 DISEASES OF CHILDREN. 

to five weeks. New-born children invai-iably succumb to it in a 
few days, and even infants several months old only recover very 
exceptionally. 

Etiology. — In new-born children erysipelas almost always starts 
from the navel, and is especially often observed during an epidemic 
of puerperal fever, when, in fact, the navel never cicatrizes normally. 
In older children all possible injuries of the skin may supply a cause 
for this disease. Erysipelas most frequently follows vaccine and 
impetigo pustules, but may also take its rise from a simple abrasion 
(intertrigo) of a cutaneous fold. But the great frequency with 
which these cutaneous excoriationo occur on the one hand, and the 
rarity of erysipelas on the other, render a positive disposition to 
erysipelas necessary to account for its appearance in these cases. 
It is sometimes met with in foundling hospitals and lying-in asy- 
lums, especially erysipelas neonatorum, and is ascribed to irritation 
produced by mismanagement of the umbilical cord ; but it is more 
likely due to some endemic cause, or some blood-dyscrasia of the 
new-born. From the umbilicus the erysipelas extends to the in- 
tegument of the abdomen, and frequently to the organs of genera- 
tion. It sometimes gives rise to sphacelus of the integument and 
subcutaneous tissue, and terminates fatally. 

Treatment. — All attempts to localize erysipelas, to prevent its 
spreading, have hitherto proved futile. Even ferrum candens (the 
actual cautery) has been tried, but has proved ineffectual to check 
the progress of the inflammation. 

The internal treatment at any rate must be by tonics and stimu- 
lants. The English physicians claim to have derived benefit from 
tr. ferri muriatici oxid. in two-drop doses every hour, In the few 
children whom I have seen recover from erysipelas, I administered 
from two to three grains of quinine daily for several days, and a 
teaspoonful of Bordeaux brandy every hour for several weeks. 
Locally ol, coccos was only applied. 

(7.) Pemphigus Benignus {contagiosus). — By pemphigus is 
generally understood the spontaneous development of a yellow bleb 
on the skin, which in no way can be distinguished />om the blister 
of a hum or of cantharidis. A very malignant form is met with in 
syphilitic new-born children, which will be described in the section on 
syphilis. In addition a benign pemphigus occurs, though rarely, 
which, albeit not of a dyscrasiac nature, still is occasionally contagious 
in a mild degree. This form preferably attacks nurslings, less fre- 
quently older children, and still more rarely adults. Instances of its 
undoubted contagiousness are mentioned by Langhans, Scharlau, 
Steffen, and others. Dohrn reports the case of a midwife in whose 



ERUPTIVE FEVERS. 445 

practice one-half of the children she handled contracted pemphigus ; 
and, although she twice ceased to jDractise her calling for periods of 
four weeks each time, yet when she resumed it new cases of pem- 
phigus appeared. I only succeeded once in substantiating its conta- 
gious character. An infant two weeks old was attacked hj multiple 
blisters and blebs ; some of them resembled varicella vesicles very 
much ; others, however, attained to the size of a pea or bean. Sev- 
eral days after, the mother of the child and nurse became similarly 
affected, but in the adults the eruption resembled that of varicella 
more than it did in the child. Later on the child was vaccinated, 
and this was followed by normal pustules, and thus the possibility 
of having mistaken it for varicella could be safely excluded. The 
number of blebs varies ; in some cases there are only a few, in others 
many dozens. The eruption by no means presents that markedly 
typical form which we see in the acute infectious diseases, but suc- 
cessive crops may appear during several successive days. As has 
been already stated, most of the vesicles cannot be distinguished 
from those of varicella, but between these there are some of the 
size of a pea or hazel-nut. The larger ones are never round, but oval, 
and their long axis is perpendicular to the long axis of the body. 
For twenty-four hours preceding the appearance of the blisters the 
skin presents a circumscribed redness ; they then burst or dry up 
like a cantharides-blister, but in all cases thin scabs form, surrounded 
by a slightly red areola, which falls off in from six to twelve days. 
No scars remain, but in exceptional cases, where diphtheritic inflam- 
mation attacks the raw surfaces, cicatrices are apt to follow, show- 
ing the former site of the blebs. The exanthemata appear by 
preference upon the face and trunk, generally sparing the extremi- 
ties entirely. The general symptoms, consisting of a period of in- 
disposition lasting from one to three days, vespertine fever, restless- 
ness, and sleeplessness, are observed only at the invasion of the dis- 
ease, and even then not in all cases. The kidney secretions are not 
interfered with in the least. 

Treatment. — Benign pemphigus, as its name indicates, runs a 
favorable course and requires no special treatment. The places 
that are denuded of epidermis, and the crusts should be protected 
from injury by the inunction of some simple fat or salve. Recov- 
ery ensues in from two to three weeks. If the local lesion becomes 
complicated with diphtheritic exudations, the internal treatment 
already recommended for the treatment of diphtheria is applicable 
here, and the sores should be dressed with an ointment of carbolic 
acid, one part of the latter to 100 of simple cerate. 



446 DISEASES OF CHILDEEX. 

SECTION 11. MIASMATIC DISEASES. 
DIPHTHERIA. 

1. DiPHTHEEiTis OF THE MoxTTH (from dicp^spa, skin, and itis). 
— By diphtheritis or diphtheria, angina membranacea, angina couen- 
neuse of the French, is understood an acute general affection, the 
most striking symptoms of which consist in an extensive formation 
of inembranes on the posterior parts of the mouth. 

Historical investigations have shown that the disease is by no 
means new, and that it was already known to Aretceus (second half 
of the first century A. d.). There are also descriptions extant of 
epidemics in Holland (fourth century), in Paris (sixteenth century), 
in Spain (seventeenth century), and in the present century it oc- 
curred most frequently in America, next in England and France, 
and lastly in Germany, and indeed predominantly in the northern 
part thereof. 

A p>rimary and a secondary diphtheria are distinguished, of 
which the latter associates itself particulai'ly with measles and scar- 
let fever, and occurs in a sporadic form, whereas the primary al- 
most unexceptionally prevails epidemically, and is decidedly con- 
tagious. 

Symptoms. — Primary diphtheria invariably begins with fever, 
marked acceleration of the pulse, increase of temperature of the 
skin, and general depression. Still, these phenomena in different 
individuals are extremely unequally developed ; this inequality, in 
fact, is only a special peculiarity of this disease, since its occur- 
rence and course, under equal circumstances and in equal ages, vary 
immensely. 

The local symptoms make their appearance after these general 
phenomena have existed for a few hours, or at the longest one or 
two days. The patients are attacked by dysphagia, a snuffling, 
somewhat hoarse voice, and stiffness of the neck ; the first two 
symptoms are due to the diphtheritic exudation coating the tonsils, 
palate, and nares, the last to the never-absent swelling of the adja- 
cent lymphatic glands of the neck. 

If the mouth is now examined by the aid of a good light, it 
will be seen that the mucous membrane of the lips, gums, cheeks, 
and of the hard palate, is perfectly intact, but that the soft pal- 
ate, the tonsils, and the posterior wall of the pharynx, are cov- 
ered with a white membrane, which, especially upon the tonsils. 



MIASMATIC DISEASES. 447 

may attain to one-lialf and even one line in thickness. The 
color of this membrane at first is perfectly white, but after sev- 
eral days it changes into a yellowish-white or grayish-white tint. 
If the affected parts have been injured by escharotics or rough 
handling, small haemorrhages ensue, in consequence of which the 
membranes assume a brownish or even blackish color. The course 
of these membranous formations varies according to the character 
of the epidemic. There are instances where the membranes have 
been cast off in two or three days, and the mucous membrane be- 
neath was seen to be uninjured ; there are other cases, and these 
form the generality, where the membranes exist for two and three 
weeks ; the mucous membrane is thereby drawn into a j)rocess 
of ulceration, and heals only after a protracted period, with visi- 
ble cicatrices ; and finally malignant cases occur, in which gan- 
grene soon manifes.ts itself, followed by general collapse, the mu- 
cous membrane undergoing a black destructive degenei-ation. In 
this last unfavorable form, marked destruction of tissue takes place, 
usually quickly followed by death, and a recovery is but very rarely 
brought about. 

If the membranes can be seen upon the places mentioned, then, 
of course, no doubt can be entertained in regard to the diagnosis. 
But in some particular cases a redness and slight swelling of the 
fauces only are noticeable, and yet all the subjective and the rest of the 
objective symptoms of diphtheria may be present. Here we have to 
deal with an exudation upon the posterior surfaces of the uvula, soft 
palate, and of the nasal cavities, as may be demonstrated by ele- 
vating the soft palate with a forceps, certainly accomplishable only 
in adults, and by the discharge of a profuse reddish-colored mucus 
from the nares. I have often convinced myself, at the post-mortem 
examination, that the anterior surface of the soft palate may remain 
perfectly free, while the posterior, on the contrary, may become 
coated with membrane. By far the most dangerous, and, in some 
epidemics, unfortunately also the most frequent phenomenon, is the 
extension of the membrane into the larynx^ which will be treated of 
more minutely further on, in the chapter on croup. 

Diphtheria is no local disease, for otherwise the vagina, excoriated 
surfaces on various parts of the body, the conjunctivae, and sometimes 
also the anus, would not become simultaneously coated with false 
membranes. 

The most common complications and sequelae to be mentioned are 
albuminuria and nephritis^ croup^ hroncJdtis, and pneumonia^ intes- 
tinal catarrh^ myocarditis^ and finally a peculiar paralysis. 

Albuminuria is said to have been observed, in severe epidemics, 



44:8 DISEASES OF CHILDREN. 

from the very commencement of the disease ; in the ordinary epi- 
demics, such a one as I witnessed in Munich in 1864, the urine at first 
is free from albumen, dark in color, and sparingly secreted. But 
later on, when the diphtheria has completely exhausted itself, a 
true nephritis occasionally supervenes, which, so far as the morbid 
changes in the urine are concerned, cannot in any way be distin- 
guished from nephritis occurring after scarlatina. The urine has a 
blood-red color, contains a large quantity of blood-globules, epithe- 
lium cells and casts, and, on boiling, reveals a correspondingly large 
precipitate of albumen. But whereas in nephritis, after scarlet fever, 
anasarca and effusion of serum into the serous cavities, rapidly and in 
a critically high degree, take place, here, as a rule, the extremities do 
not swell, and dropsical effusions into the large serous sacs are 
still more rarely met with. Usually, this nephritis terminates in 
recovery, but for it we often have to wait many months, and it does 
not occur until an alarming general emaciation has set in, attended 
by a gradual decrease of the albumen. The absence of dropsy 
is most readily explained by the fact that in scarlatina both 
kidneys are almost always affected ; in diphtheria probably only 
one is implicated, while the other remains in a normal condi- 
tion. 

Bronchitis and pneumonia^ as complications of diphtheria, will be 
more advantageously spoken of in connection with croup. 

Myocarditis^ molecular degeneration of the cardiac muscle, is a 
tolerably regular pathological condition found in cases of sudden 
death, and occurs more or less frequently in every severe epidemic. 

Intestinal catarrh^ during and after diphtheria, in small children 
who are still laboring under dentition difficulties, is often of a very 
protracted duration, and, conjointly with the increasing anaemia, fre- 
quently leads to death. 

The diphtheritic ^ara^ysis is of an extremely peculiar nature ; its 
connection with diphtheria has been pointed out by Orillard only 
within the last decade. As regards the frequency of this phenomenon, 
it is extremely variable in different epidemics. In some epidemics 
almost all convalescents are said to manifest symptoms of paralysis ; 
in others, again, for example in the one I witnessed, but a small num- 
ber were so affected. The time of its occurrence happens mostly in 
the third or fourth week from the invasion of the disease, not often be- 
fore ; sometimes, however, much later, so that its subjects may seem 
to have enjoyed perfect health for from six to eight weeks, and still 
be liable to be attacked by paralysis. It begins almost invariably at 
\he palate. The children suddenly get an indistinct snuffling speech, 
as is witnessed in persons with congenital or syphilitic-acquired defect 



MIASMATIC DISEASES. 449 

of the palate, and the gutturals in particular are pronounced with ex 
treme difficulty. At the same time embarrassed deglutition ensues, 
and a part of the swallowed drinks, with or without a spasmodic 
cough, flows out ai the nose. In most cases the paralysis remains 
confined to this small space ; the general condition of the system, 
with the exception of a remarkable bloodlessness, is not perturbed, 
and the complication usually terminates in sudden recovery after sev- 
eral weeks. The prognosis assumes a far worse aspect when the ex- 
tremities also become paralyzed, and in paralysis of the muscles of the 
body death usually ensues in consequence of the laborious, difficult, 
and imperfect respirations. Paralysis of the extremities occurs more 
frequently in the lower than in the upper, in most instances is bilateral, 
and is in no way to be distinguished from that occurring after typhus 
or scarlet fever. 

Lastly, the diphtheritic amaurosis is also remarkable. The loss 
of sight is not complete, but consists only in a diminution or weakness 
of vision, smaller objects not being distinctly perceived. Ophthal- 
moscopically, no constant morbid changes can be demonstrated, and 
specialists, according to the precepts of Donder, assume the existence 
of a paralysis of the sphincter iridis, and of the tensor choroideae 
muscles. This evil, as a rule, also disappears completely in a few 
weeks. Relapses of all of these paralytic symptoms have been ob- 
served, but seem to be very rare. 

Pathological Anatomy. — The essential anatomo-pathological con- 
dition seems to be the existence of false membranes, which most fre- 
quently occur on the posterior parts of the mouth, pharynx, and larynx. 
They are usually yellowish white, but in the cadaver, especially where 
the mouth has been open, they soon become darker, brown, or blackish, 
as a result of desiccation. Sometimes they can be removed with 
ease, at other times with difficulty, from the subjacent mucous mem- 
brane, and the latter, as a rule, displays no loss of substance, only a 
diminution of its natural gloss. The microscopic examination of these 
membranes furnishes few important facts. They consist in greater 
part of granules and cells, solitary epithelium-cells, and striae of 
fibrine. The morbid changes in the larynx and lungs will be de- 
Boribed further on. 

Treatment. — The most varying, totally antagonistic views prevail 
concerning the treatment of diphtheria, from which alone it follows 
that all the remedies hitherto employed are of doubtful efficacy. Since 
the site of the disease is within easy reach of hand and eye, a local 
treatment has always been recommended and persisted in. There is 
no escharotic that has not already been tried in this disease. Of this 
class of agents, nitrate of silver and muriatic acid have acquired the 



450 DISEASES OF CHILDREN. 

greatest reputation. Of late, some very eminent English physicians 
have abandoned these escharotics altogether, and found that the result 
of their treatment is by no means less favorable ; on the contrary, 
even somewhat better. In view of these considerations, I have for the 
last two years totally abandoned the cauterizing treatment, and by 
hundreds of cases convinced myself of the correctness of those state- 
ments. I may declare with a perfectly clear conscience, and to the sat- 
isfaction of the numerous tormented diphtheritic children, that cauter- 
ization with the substances hitherto used has no favorable influence upon 
the local affection. In somewhat older patients, say up to five years of 
age, I prescribe the inhalation of pure lime-water five to six times daily 
for at least five minutes at a time, by the now very simplified pulveri- 
sateur, and have derived remarkably good results from this mild and 
considerate treatment, to which children of this age may by kindness 
be induced to submit. Internally, for many years past, I have given 
nothing but chlorate of potassa : to children under one year, 3 ss — 3 i ; 
of one to three years, 3 ss ; of three to five, 3 ij ; to still older ones, 
3 i, in twenty-four hours, dissolved in several ounces of water. "SMien 
diarrhoea or great restlessness is present, an appropriate dose of opium 
or morphine may be added with advantage. Carbonate of soda, in 
quantities of 3 i /'^o die^ praised so much by the French as a specific 
for this disease, has not proved itself as such in this countrj^ and is 
really far inferior in its efi"ects to the chlorate of potassa. When the 
strength begins to fail, the system should be supported by wine, qui- 
nine, camphor, castoreura, etc. 

[Diphtheria is now generally recognized as a constitutional dis- 
ease. In its milder form the local aflfection of the throat constitutes 
its entire pathogeny ; in severer cases it is complicated with high 
fever, albuminuria, paralysis, and arthritis, and may terminate in 
sudden death. It undoubtedly originates de novo, but is admitted 
by the best authorities to be contagious, especially when it pre- 
vails in an epidemic form. The contagious principle is said by Ger- 
hardt to be produced by the diseased mucous membrane, affects the 
breath, and may be transmitted by various fomitre, such as bed- 
linen, clothing, etc. It is not of a gaseous nature, but only sus- 
pended in the breath, and is arrested by the projecting tonsils, 
especially if they are swollen and the mucous follicles are distended 
and their mouths patulous. According to JacoM, " any abnormal 
state of the mucous membrane affords an excellent abode for diph- 
theria." * Catarrhal pharyngitis and follicular amygdalitis predispose 
to the disease. It has an incubation period of from two to fourteen 

* Jacobi, " Treatise on Diphtheria." 



MIASMATIC DISEASES. 451 

days, and is essentially a disease of childhood, having been observed 
in infants as young as five months. Still, it is also frequently seen 
in the adult, and one attack does not exempt an individual from 
additional attacks. It is claimed that damp residences favor the 
development of the disease ; it is certainly oftener met with in cold 
and wet weather, probably because catarrhs and colds favor the pro- 
duction of ordinary sore throat. Recent investigators have claimed 
the presence of bacteria in the blood of diphtheritic patients ; oth- 
ers, again, look upon the bacteria as a " pathological cellular for- 
mation, originating within the cells, and not introduced from with- 
out." 

The constitutional symptoms and sequelae, already alluded to, 
would seem to point to a general infection of the system and 
of blood-poisoning. Many of the acute exanthematous diseases 
favor the development of dii^htheria, but none so constantly as 
scarlatina. In some epidemics of scarlet fever almost every case 
is complicated with or followed by this affection. Hence some 
authors regard diphtheria and nephritis as scarlatina sine exan- 
themata, and the contagious principle as being identical in both 
diseases. 

The disease is usually ushered in by a chill, especially in older 
children ; in infants, an attack of convulsions or of vomiting may 
be the harbinger of this affection ; then follows fever, more or less 
intense, but which, in many cases, bears no exact relation to the 
severity of the infection. In the milder form the temperature may 
not rise over 102° Fahr. ; in the severer to 104°, or even 105°. It 
generally begins in about two days after an exposure to the con- 
tagion, though the period of incubation, as already stated, may be 
extended to fourteen days. By this time there are already present 
pain on swallowing, and minute yellow dots upon the tonsils or 
pharynx, which soon assume the characteristics of pseudo-mem- 
bi-ano. The gravity of the disease is not due so much to the exten- 
sion of the morbid process, but to the change which the already 
affected structures undergo. Hence the danger of the disease is 
not commensurate with the height of the fever. 

We frequently meet with cases where the disease seems to be 
ushered in with the utmost intensity and rapidity, overpowering 
the system at once, and which may be denominated as the fulmi- 
nant form. Here the local morbid lesion on the tonsils attains to the 
greatest degree of destructive inflammation in a very short time, a 
few hours being sufficient to produce a sloughing, putrid ulcer, 
emitting a fetid odor, and adding the danger of poisoning the sys- 
tem by septicaemia. Quite recently, I watched this morbid process 



452 DISEASES OF CHILDREN. 

developing itself in an apparently healthy lad thirteen years of 
age, who in the evening complained only of slight pain on swallow- 
ing, and on the next morning the disease was fully developed — 
sloughing ulcers on the tonsils, fetid breath, tumefaction of the 
glands, fever, and rapid pulse. He finally recovered, but his recov- 
ery was retarded, first by paralysis of the palate, next by amau- 
rosis, and lastly by paralysis of his lower extremities, the disap- 
pearance of the first paresis mentioned being followed by the 
second, and the second by the third, at intervals of from ten to 
fifteen days. 

In these cases the fever does not always bear an exact relation 
to the intensity of the disease, the thermometer never rising above 
100° F., as was the case in the patient mentioned above. 

The diagnosis of diphtheria is in most cases quite easy to estab- 
lish — the only affection it is liable to be mistaken for being aphthae, 
and this is readily differentiated by an examination of the false 
membrane under the microscope. There is a likelihood of over- 
looking a mild attack of scarlatina, but the diphtheritic affection 
will nevertheless be recognized by its attendant train of symp- 
toms. 

As a prophylactic measure, to be adopted for the purpose of 
checking the spread of the disease, the patient should be isolated, 
and the healthy children removed from the infected house. All 
persons affected with the least throat trouble should be zealously 
looked after, especially those suffering from chronic tonsillitis and 
catarrhal pharyngitis. During the prevalence of an epidemic it is 
well to examine every person in the house daily before attending 
to the patient. 

Gerhardt claims that, by carefully cauterizing the starting-point 
of the disease, it is often possible to abort it. Among the escharotics 
which he recommends are argent, nitric, chromic and acetic acids, 
and kali causticum ; but he adds that repeated cauterizations of the 
throat will not cure the disease, but, on the contrary, increase the 
inflammation and tend to extend the morbid process. 

I have long ago abandoned the use of escharotics in the treat- 
ment of diphtheria, and learned to rely upon the use of chlorate of 
potassa and chloride of iron, both of which I give in large doses, 
frequently repeated, and upon stimulants and nutritious food, such 
as milk, eggs, ice-cream, etc. 

The form of stimulants I prefer is the best brandy — given in 
large doses, from the very commencement of the disease, or at 
least as soon as I am called to see the patient — mixed with milk, 
eggs, etc., commonly called egg-nogg. There is no fear of giving 



MIASMATIC DISEASES. ^ 453 

too large quantities of alcohol to patients suffering from this disease, 
especially in the septic form, where they are in danger of sinking 
rapidly from the intense blood-poisoning and failure of the heart's 
action. No absolute rule, however, as to quantity and frequency 
of giving stimulants, can be laid down for all cases ; each case 
must receive the attention it merits, the condition of the pulse being 
the best criterion for that purpose. Where the ulcerations of the 
fauces are so severe as to prevent the patients from swallowing, 
the stimulants should be administered hypodermically, or by the 
rectum, well diluted with water or milk ; and liquid food, such as 
milk and the like, may also be injected into the bowel. I have had 
more satisfactory results from this method of treatment than from 
any other hitherto recommended.] 

(2.) Diphtheritic Ceoup {Laryngitis and Tracheitis Malig- 
na). — It is not easy to find, for one and the same disease, so many 
and different appellations as for croup. The most current are : 
Cynanche trachealis ; angina laryngia exudatoria, sive polyposa, 
sive memhranacea, sive strepitosa-perfida-mortalis ; laryngea tra- 
cheitis exiiditava, pharyngo-laryngitis pseudomemhranacea ; mor- 
biis strangulatoriiis j suffocatio stridida ; membranous quinsy. The 
shortest of all of these titles, croup, has received the preference, and 
in the Scotch vernacular properly expresses a white membrane found 
upon the tip of the tongue of sick chickens, in the disease called 
" pip." 

In ancient times croup seems to have occurred very rarely ; for 
not even one characteristic description can be found in the writings 
of the old physicians, whose accurate powers of observation no one 
will presume to question. JBaillou, in 1576, according to Fredrich, 
is the first who mentions having undertaken a dissection of croup. 
The literature of croup received a great accession through the pro- 
claimed concours of Napoleon I., occasioned by the rapid death of 
his nephew, the son of the then King of Holland, who fell a vic- 
tim to this disease in 1807. Eighty-three dissertations on croup 
were sent in. Jarine, of Genf, and Albers, of Bremen, received 
prizes, and many others were honorably mentioned ; none, how- 
ever, knew of any remedy by which the mortality of the disease 
could in any way be ameliorated. As Napoleon was chiefly con- 
cerned about the latter, and not in the enriching of the symp- 
tomatology or the pathological anatomy of croup, the writings of 
the entire concoicrs must therefore be regarded as having disap- 
pointed him. 

Pathological Anatomy. — Croup consists of a certain group of 
symptoms, which in different individuals always manifest them- 
30 



454 DISEASES OF CHILDREN". 

selves in the same manner. "We do not intend to be understood as 
saying that these symptoms are always indicative of the same 
anatomo-pathological alterations ; on the contrary, there is abun- 
dant evidence that it may depend upon three different kinds of pro- 
cesses upon the mucous membrane of the larj-nx. The exudation 
poured out by the inflamed mucous membrane may be either (a) 
muco-purulent, or {b) simply fibrinous, or (c) diphtheritic. 

(ad a.) The laryngeal mucous membrane, which, during life, is 
probably intensely red and strongly injected, does not generally re- 
tain that color after death, but is only slightly reddened ; its inflam- 
matory swelling, however, continues, and may be readily demon- 
strated by a perpendicular incision. This inflammatory thickening 
is also found in the glottis. The entire larynx and trachea are hned 
by a tenacious, yellowish mucus, which is with difficulty wiped away. 
In some places the inflamed mucous membrane displays small catar- 
rhal abrasions, and its follicles are enlarged, so that, when the mu- 
cous membrane is rendered tense by bending or twisting the trachea, 
a minute bead-like drop of grayish-white mucus will rise out from 
every cr^^pt. This muco-purulent exhalation may extend down into 
the very smallest bronchi. 

(ad 5.) With the condition just described, which, in fact, must 
necessarily be found in every dissection of croup, a fibrinous exuda- 
tion of more or less thickness usually becomes associated, and may 
be readily peeled off from the inflamed mucous membrane without 
causing any actual loss of its substance. Microscopically these mem- 
branes consist of band-like fibrinous cords, between which numerous 
pus-cells are deposited. The latter did not originate in the fibrine, 
but were already previously present upon the mucous membrane, and 
subsequently became surrounded by the fibrinous exudation, and 
locked in by the coagulation that ensued. The membranes vary very 
much in extent. Sometimes very thin, cobweb-like, small patches 
are found at one or several places of the larynx ; in other cases the 
membranes are of the thickness of the back of a knife, yellowish- 
white in color, covered on their upper surface by a cream-like coating, 
and line the entire larynx, trachea, and the bronchi of the higher 
order, so completely that they appear like a prepared connective, 
dentritic tubular system, and may be pulled out entire. The tonsils 
and pharynx are also occaspnally seen to be coated with these mem- 
branes. 

(ad c.) In diphtheritic laryngitis a grayish-white exudation into, 
not upoUj some portions of the mucous membrane is poured out 



MIASMATIC DISEASES. 4.55 

This grayish mass of exudation, beneath which the mucous mem- 
brane, as well as the epithelium, is soon destroyed, consists of an 
amorphous detritus, in which no hands of fihrine and but few pus- 
ceUs are found. It is not as easily pulled off from the mucous mem- 
brane as the simple fibrinous membrane, and generally covers also 
the palate, tonsils, and pharynx. The distinction between purely 
fibrinous and diphtheritic croup is entirely a microscopical one. 

When the diphtheritic layer becomes detached during life, an 
ulcer remains behind, the margins and base of which soon become 
coated with a new grayish deposit. Diphtheria, according to 
Virchow's views, is to be regarded as a progressive inflammation, 
with partial destruction and sloughing, of the mucous membrane. 
Diphtheritic laryngitis occurs in an epidemic form, and frequently 
follows upon morbilli and scarlatina. 

The pulmonary parenchyma is found altered in all the three forms. 
Usually the lungs do not collapse on opening the thorax, because the 
air in the bronchi is prevented from escaping by the mouth, by the 
large quantities of bronchial secretion; often diffused pulmonary 
oedema and very generally lobular, sometimes also lobar pneumonia 
or tuberculosis, are present. 

The adjacent lymphatic glands of the neck and nape, as well as 
the bronchial glands, are often swollen and h3rperEemic. 

The rest of the organs, with the exception of venous stasis, ex- 
hibit no characteristic morbid changes. 

Symptoms. — The prodromata of croup are seldom particularly 
significant. The children have a cough, sneeze, and suffer loss of 
appetite for a few days, and sometimes are less lively than usual ; 
still, it also happens that they retire to rest perfectly well and serene, 
and, after sleeping the first hours of the night, suddenly wake up 
with a croupy cough, upon which the symptoms may develop them- 
selves so rapidly that the physician who is called in on the following 
morning finds a complete, well-marked croup. This first stage, the 
stadium prodroraorum, is not noticeable, simply for the reason that, 
in many cases, it does not occur at all, and, in still more, offers no 
pathognomonic sjnnptoms whatever. 

The commencement of croup is, with justice, dated from the mo- 
ment in which the first morbid change in the larynx manifests itself 
through the voice and cough. The voice becomes hoarse and husky, con- 
stantly lower and lower, till it finally disappears so completely that 
their efforts to speak can only be heard in their immediate vicinity 



456 DISEASES OF CHILDREN. 

Even the most intense pain or anger does not enable the child to utter 
a loud sound. As soon as the voice becomes hoarse and rough, a res- 
piration, audible throughout the room, supervenes. The sounds ac- 
companying the breathing are best imitated by pointing the lips as 
if about to whistle, but, instead of whistling, you merely inspire and 
expire through the sharply-pointed lips. A sound is thus pro- 
duced which is midway between an active breath and a whistle. In 
croup it approximates more to the active breathing than the whistling 
tone. The inspirations constantly grow more frequent, and finally 
the number of respirations may rise to sixty and more in the minute. 
They also become irregular, sometimes deep, sometimes superficial, 
and the accessory muscles of the respiratory muscular apparatus par- 
ticipate more and more in every act of respiration. 

Simultaneously with the hoarseness and the loud breathing, a 
cough supervenes, the tone of which is so characteristic that, for 
brevity, it has been called " croup cough." It is a barking, toneless, 
dry cough, and has been compared, not inapjaropriately, to the first 
attempt at crowing of a young- rooster. At first it is tolerably ab- 
rupt, and terminates with a single exjjiration ; soon, howev' er, it be- 
comes a regular paroxysm of cough, which may last one and subse- 
quently several minutes. In the first day of croup these severe 
cough paroxysms are rare, and recur only every four or six hours. 
Soon, however, they become aggravated in intensity, as well as in 
frequency, and are quickly induced by the least external irritation, by 
drink, or pressure on the tongue, for the purpose of examining the 
throat, etc. They abate, and even disappear altogether, at the ap- 
proach of death. In consequence of this cough, children become 
livid in the face, the eyes protrude, staring and congested, from the 
sockets, the veins of the neck and head swell up into thick tense 
cords, the forehead becomes covered with perspiration, but the cough, 
notwithstanding the most violent exertions, remains totally aphonic, 
accompanied by the expectoration of only small quantities of frothy 
mucus. These paroxysms of cough are distinguished from those of 
whooping-cough, which are also interrupted by a whistling inspiration, 
by their suffocative character, aphonic tone, by the absence of expec- 
torations, and vomiting. Moreover, in pertussis, the child is well 
immediately after the termination of the paroxysm, and the voice 
is natural, while croup patients are seriously sick, and the voice is as 
much aphonic afterward as before. 

It is a mistake to ascribe the croupy cough and the loud breathing 
to true croup only, and to consider all the laryngeal affections in which 
this cough is heard as genuine croup. To this error, no doubt, a great 



MIASMATIC DISEASES. 457 

many of the recoveries from attacks of croup, in wMch a few leeches 
or some other therapeutic procedure rendered such "excellent ser- 
vice," are due. Very simple, mild cases of laryngitis often occur in 
which children have no fever at all, and retain their appetite, but 
which nevertheless are accompanied by the same hoarseness, the same 
tone of the cough, and the same loud respirations, for many days to- 
gether. This condition may even become chronic, may be produced 
by hypertrophied glands growing aroimd the trachea, and last for 
many years. 

In genmne croup, an increased temperature of the skin is present 
from the very first, by which, in fact, the general disease manifests it- 
self. The acceleration of the pulse is, in this disease, as in most in- 
fantile diseases, of little significance, since even a trifling catarrh will 
produce it. Croupy cough, hoarseness, and loud respirations, do not 
suffice for a diagnosis of croup ; the symptom of continuous fever must 
be present. This consists, above all, in a marked, perceptibly-in- 
creased temperature of the skin, in loss of appetite, in augmented 
thirst, and in acceleration of the pulse. 

Concerning the a^Dpearances of the mouth, authors of various coun- 
tries dififer according to the countries in which they have carried out 
their investigations. In France, particularly in Paris, where the diph- 
theritic croup seems to occur almost exclusively, it is a rare exception 
to find a child with croup who has not its posterior pharyngeal wall, 
tonsUs, and palate, of a dark-red color, covered with tenacious mucus, 
and even with diphtheritic exudation. In the many patients with 
this disease whom I have had to treat in Mimich, I have hardly seen 
a membrane, rarely any thick mucous coating, and only a moderate de- 
gree of redness of the posterior parts of the mouth. The case is dif- 
ferent again in middle and north Germany, where membranes are 
often found upon the tonsils, and severer pharyngitis is observed, 
while English authors consider croupous angina as an exceptional oc- 
currence. The reason for these diverse statements is found in the 
diversity of the anatomo-pathological process. In the one case, croup 
is produced simply by a plastic exudation within the larynx, which 
does not generally extend above the epiglottis ; in the other by diph- 
theritis, which almost always occurs simultaneously upon the tonsils. 

Auscultation of the lungs always reveals widely-diffused sonorous 
rales, but the whistling laryngeal breathing is so intense that it com- 
pletely obscures the vesicular breathing. If the croup has existed for 
one or two days, circumscribed or more extensive dulness and bron- 
chial breathing, especially over the back, will also be found, due to 
lobular or lobar pneumonia. In rachitic children, acquired atelec- 
tasis and rachitic camification of the lungs rapidly increase in circum 



458 DISEASES OF CHILDREN. 

ference, and become surrounded by pneumonic infiltration. The expeo- 
toration, as has been already stated, is mostly slight, a frothy white 
mucus, but occasionally croupous membranes are coughed up during 
the paroxysms, representing sometimes single patches with fringed 
borders, sometimes entire closed tubes of greater or less calibre, ac- 
cording to size of the air-tube from which they have been detached. 
With the expulsion of such membranes, little or but a temporary 
amelioration takes place, and the prognosis consequently does not 
improve in the least. This is now a well-established fact, and yet 
physicians do not cease to tortvire the poor croupy children with emet- 
ics, and triumphantly pull out a membranous piece from the vomited 
matter, and, when death ensues notwithstanding, as it usually does, 
" the doctor is supposed, at any rate, to have done his duty." 

Slight compression of the larynx generally causes severe pain, 
while deglutition is only embarrassed and painful when the tonsils and 
fauces are also implicated, a condition usually not present in this 
country. The bowels are generally constipated, and the urine is nor- 
mal, or shghtly reduced in quantity. 

If the symptoms hitherto depicted have lasted for one, or at 
the most two days, the eifects of embarrassed resj^iration supervene. 
The lips, cheeks, and tips of the fingers, become cyanotic, the dyspnoea 
intense, the child sits upright in bed as long as its strength will allow, 
and keeps the head extended backward. All the accessory respiratory 
muscles are in a state of the utmost activity, so that the head, with 
every inspiration, is made to approximate the chest. With the des- 
peration of deathly fear they tear the clothes from the breast, and 
pull at the neck as if they would try to remove the cause of their 
dyspnoea. The little hands, with cramp-like tenacity, grasp at the 
sides of the cradle, or some other firm object near them, so that the 
pectoral muscles may the better serve as respiratory muscles. They 
never remain long in one posture, and, by constantly changing their 
position, seek to obtain an endurable attitude. The pulse becomes 
almost uncountable, unrhythmical, and uneven. Several hours before 
death a remission of all the symptoms usually takes place, the dysp- 
noea diminishes, yet the respiration remains accelerated, the child 
again lies down upon the pillow, its expression of extreme anxiety has 
disappeared, and that of indifference or of unconsciousness has taken 
its place. The inexperienced parents usually regard this condition as a 
commencing improvement, but to the physician the clammy cold 
sweat, the increasing cyanosis, the unequal, uncountable pulse, prog- 
nosticate a speedy end. 

As regards the explanation of the dyspnoea, and of the paroxysms 
of cough, it is usually assumed that the former is produced by the 



MIASMATIC DISEASES. 459 

croupy membranes, the latter by a spasm of the glottis. But against 
these suppositions weighty objections appear. The diligent physi- 
cian, who does not omit to examine every child that dies from croup, 
knows that the thickness and extent of the croupous membranes do 
not stand in exact relation to the symptoms observed during Kfe. 
Where, on account of the most violent dyspnoea, abundant membra- 
nous formations are expected, only a few, circumscribed, gauze-thin 
patches are present ; and, conversely, where the croup produced less 
horrible symptoms, the whole larynx, the entire trachea, and even the 
bronchi, on dissection, are often seen to be lined with tubular mem- 
branes, of the thickness of the back of a knife. Consequently, it seems 
to depend more upon the degree of the oedematous swelling, which 
implicates the mucous membrane of the glottis, than upon the mem- 
branous formations. The oedema of the glottis, however, almost 
always escapes the notice of the pathological anatomist, on account of 
the change of its form that has taken place. 

SGhlautmann offers valid objections against the theory of spasm. 
He contends that, in such a kind of inflammation of the mucous mem- 
brane, a paralysis of the subjacent muscles takes place as a result of 
the cedema, and compares croup with the symptoms observed in ani- 
mals after division of the pneumogastric nerve. When this operation 
is performed, it also causes the most violent dyspnoea, implicating all 
the auxiliary respiratory muscles ; there is prolonged inspiration, accom- 
panied by a noise, and short expirations. The deep, rough, hoarse 
tone of the voice, as well as the cough, much more probably indicates 
paralysis than spasm of the glottis. In the latter condition, the chordae 
vocales are in a state of extreme tension, and, consequently, give high 
tones, not deep, rough ones. Again, in every inspiration, the chink 
of the glottis is dilated by muscular contraction, but, when this is abol- 
ished, it will flap hither and thither, like a loose sail, and exposure of 
the glottis, after division of the N. vagi, has demonstrated that the 
paralyzed glottis contracts in every inspiration, particularly when the 
act is a forced one. Thus the dyspnoea is greater in animals with 
paralysis of the laryngeal muscles when the animal is stimulated to 
deep inspirations. The case is similar in children affected with croup. 
So long as the child can breathe calml}^, it is not much annoyed, but, 
during coughing, crying, and on waking from sleep, when deep inspi- 
rations always take place, the paralyzed glottis becomes closed, and 
the symptoms of the most violent dyspnoea are induced. Thus, then, 
the older view of spasm of the glottis is tolerably well refuted by this 
[Schlcmtmann' s) statement, and must give place to paralysis, unless 
further physiological experiments should give this discovery a new 
signification. 



460 DISEASES OF CHILDREN. 

Striking as the symptoms of croup are, still, the diagnosis is by no 
means easy, and, in this disease more than in any other, both inten- 
tional and unintentional errors occur. For the purpose of confirming 
the diagnosis of true croup, it is requisite that (1) the symptoms of 
continuous fever, hot, dry skin, rapid pulse, loss of appetite, and men- 
tal depression, be present ; (2) croup cough, (3) hoarseness, (4) loud, 
croupy breathing ; and (5) suffocative attacks. In this condition, the 
posterior parts of the mouth need not necessarily be altered, but in 
diphtheritis they are generally covered \vith a white, island-like exuda- 
tion. If any one of the symptoms just enumerated is absent, particu- 
larly when the fever is not decidedly pronounced, then we have no 
croup before us, but a simple catarrhal laryngitis, without any danger- 
ous swelling of the mucous membrane, a condition that has been called 
pseudo-croup^ which, it is true, after several days, may run into the 
most complete genuine croup, and terminate in death. This is most 
probably the form in which, at the autopsy, no membranes, but thick, 
tenacious mucus, and redness and swelling of the laryngeal mucous 
membrane, are found ; the symptoms during life, however, were not 
less violent than in the membranous form. 

From the lack of harmony between the symptoms and the antomo- 
pathological process, it seems to me that it may be justly concluded 
that croup is no local laryngeal affection, but a general disease, a tox- 
aemia, perhaps, with localization upon the larynx, and that the laryn- 
geal phenomena may stand in about the same relation to the whole 
disease as the tj-phous ulcerations to abdominal tj'phus. A further 
proof that diphtheria, at least, is no local affection, is derived from the 
formations of membranes upon a blistered wound on the sternum, 
for example, when a blister is applied, according to IJiizsinsJcy's 
method, upon such a croupy child. The raw surface will become cov- 
ered, once or twice daily, M'ith false membrane, which has the greatest 
resemblance to those diphtheritic depositions upon the laryngeal mu- 
cous membrane. And only in this manner is it possible to explain why 
early and skilfully-performed tracheotomy can be so uniformly fruitless, 
for the trifling effects of this operative procedure, when practised in 
other laryngeal affections, cannot possibly be the cause of its total 
uselessness in croup. 

Occurrence and Course. — Tlie diphtheritic croup, which comes on 
particularly after scarlatina, is markedly contagious, and very frequently 
attacks several children of one family one after the other. In that 
form characterized by simple fibrinous depositions this contagiousness 
is not observed. The latter form occurs most frequently during the 
prevalence of cold, sharp north and east winds. I have, however, seen 
it at all times of the year, and under all conditions of the weather. 



MIASMATIC DISEASES. 4.QI 

In Germany croup is a rare disease, and the busiest physician 
meets witli it six or, at the most, ten times a year. It, therefore, ap- 
pears incomprehensible how so many physicians can speak of epi- 
demics of croup. To constitute an " epidemic," the sickening of large 
numbers of persons is certainly necessary, and this is never observed by 
us as respects croup. The period of life most susceptible to croup ex- 
tends from the iirst to the twelfth year, the majority of the patients 
being between the second and seventh year. In the nursling age it 
occurs extremely infrequently, and the histories of cases to which no 
post-mortem report is annexed, therefore, merit very little reliance, 
because it is very easy to confound it with spastic affections of the 
larynx, so common in this age. 

The course of the disease is extraordinarily rapid. The shortest 
time I have known, from the invasion of the malady till death, was 
twenty-one hours ; the longest, eight days. The termination is 
almost always fatal. I have never yet seen a child recover from the 
genuine fibrinous croup, but from the diphtheritic form three children 
out of twenty or twenty-five have recovered. In these cases, the chil- 
dren did not fully regain their strength till after many weeks ; the 
hoarse voice and barking tone of the cough remained longer than the 
rest of the symptoms. Nothing could be seen of any expectorated 
nor vomited membranes, notwithstanding the most careful and con- 
stant watching. The symptoms began to subside in from eight to 
ten days from the beginning of the disease, and passed off gradually ; 
their ability to partake of some lukewarm milk, without being subject 
to paroxysms of coughing, was slowly regained ; the fever abated, the 
dyspnoea diminished so much that they were able to lie down, and to 
sleep a few hours at night. The urine was discharged in larger quan- 
tities, with copious precipitates of urates. For a long time they re- 
mained very pale, emaciated, and debilitated. 

I am unable to answer the question, in regard to relapses of croup, 
from personal experience, for my three recoveries, one of which re- 
lapsed, will certainly not allow me to form an authoritative conclusion. 
The most experienced authors, such as Valleix and Guersant, express 
themselves against the possibility of relapses, but Host relates a case, 
in which genuine croup occurred twice in the same child, and, on both 
occasions, eventuated in the expulsion of membranes. When some 
mothers relate that their children have had the croup five and six 
times, they no doubt announce the result of an intentional or uninten- 
tional deception on the part of the attending physician. I once at- 
tended the children of a family, the oldest of whom, it was said, had 



462 DISEASES OF CHILDREN. 

suffered croup six times in early life. Three times the chUd was 
treated by the then family physician by venesection, and the other 
three times by leeches, the cicatrices of which were still visible in 
large numbers on the neck, and, on every occasion, numerous emetics 
were administered. The results of this oft-repeated, energetic treat- 
ment were — ^in the case of one of the children, a boy — that he has 
been very much dwarfed in body, is constantly ailing, and is also very 
slow in developing his mental faculties. When one of his younger 
sisters fell sick with croup, as the mother supposed, she sent for me, 
but, instead of croup, I found only a feverless catarrhal laryngitis, 
with hoarseness, croup-cough, and croupy breathing. Under a simple 
treatment, with solution of carbonate of soda ( 3 j to water 3 iv), a 
tablespoonful every hour, all the symptoms subsided in a few days. 
In the course of two years, this affection recurred in this child several 
times, yet the same treatment was always adopted, with the same 
favorable result, and the child has not been distiorbed in its develop- 
ment in the least. The shrewd mother maintained that the croup-at- 
tacks of her older child differed in no respect from those of the younger, 
except that the former was always a much longer time in recovering 
from each attack ; this difference, as well as defects of development, 
she no doubt justly attributes to the former methods of treatment. 

The p}'Off?iosis in well-declared croup may be set down as fatal. 
It is most unfavorable in purely fibrinous croup occurring in hitherto 
healthy, well-developed children. Such children enjoy no advantage 
over feebler ones in tliis disease, except that they are often able to 
resist its destructive force a day or two longer, but they perish just as 
surely. In diphtheritic croup, especially after measles, a recovery 
now and then takes place, upon which the treatment, as we will see 
further on, has no very remarkable influence. Where collapse, cyano- 
sis, and an uncountable pulse have supervened, there speedy death 
may be prognosticated with certainty. 

Treatment. — There is no disease, with the exception of epilepsy 
perhaps, in which so many remedies and methods have been recom- 
mended as in croup. This analogy is not only remarkable in regard 
to the diversity of the remedial agents, but also in regard to their 
efficacy in these two diseases. 

The older school of the present century, which regarded every 
patient suffering from an inflammation as lost, unless a large quan- 
tity of blood could be extracted, insisted, of course, that m laryngeal 
croup — the most acute of all inflammations — venesection and leeches 
should be employed. This was carried out to such an extent that 
even the jugular vein was advised to be opened, because from it 



MIASMATIC DISEASES. 463 

more blood could be obtained, and only the difficulty attending the 
arrest of the bleeding from it served to prevent this measure from 
being generally adopted. In phlebotomy, one and a half ounces of 
blood were counted for every year of life, twice as many leeches were 
always applied as the child numbered years, and the region of the 
sternum was preferred to the neck, because on the latter no compres- 
sion could be exercised, and it might, therefore, be difficult to arrest 
the haemorrhage. I am not able to speak of the effects of venesection 
from my own experience, for I have never seen a child with croup 
treated in this manner. But it is now discarded as inadmissible, even 
by the advocates of venesection in general. I have often already no- 
ticed the effects of leeches, and must candidly confess that they do 
decided harm. The patients are very much frightened at them, and 
strive, with all their might, against their application. As a result, 
the dyspnoea and suffocative attacks are rather aggravated than 
diminished, and collapse is generally hxu-ried on. But, if the phy- 
sician err in the diagnosis, a very possible occurrence in the early 
stages of the disease, and it is only in this stage that any benefit is 
claimed for the application of leeches, there is great liabiHty of apply- 
ing them in cases of larjiigeal catarrh. This would be not only a use- 
less application, for the disease gets well without them, but one which 
would probably materially retard convalescence. 

Emetics in croup have always found decided favor with most phy- 
sicians, although the entertained theories of their action have been 
as various as the size of the doses and manner of employing them. 
While some seek a specific effect in remedies which j^roduce emesis 
— in tart, emetic.^ in cup. sulphur.^ and even in ipecacuanha — others 
regard the act of vomiting, induced by these agents, as the essential 
result. The advocates of the first doctrine disputed for a long time 
with each other whether tart, emetic.^ or cup. sulph.^ alwn, or zinc, 
sulph., were the best remedy ; whether the disease must be attacked 
by larger or minute doses. Under these circumstances, many extrava- 
gant, absurd, and protracted therapeutical torturings of children with 
croup took place. These unfortunate victims of incessant dyspnoea 
had, therefore, to struggle through the last days of life against an 
equally unbearable condition, viz., constant nausea, i. e., against an 
artificially induced sea-sickness. Nauseants, 'therefore, having proved 
inefficacious; to continue to administer them in small doses is unjustifi- 
able. It has also been claimed that it was difficult to make children 
with croup vomit, and that, therefore, they required larger doses for 
that purpose. But this supposition has reference only to that stage of 
croup which precedes the agony of death, in which the pulse is nearly 
imperceptible, and collapse is supervening. At the invasion, however, 
of the disease, they will vomit from any emetic like other children, 



464 DISEASES OF CHILDREN. 

and an infusion of ipecacuanha ( 3 j of the root to f j of water) will 
induce it. It cannot be denied that the act of vomiting, repeated one 
to three times, often has a very good effect upon the dyspnoea, by ex- 
pelling from the larynx loosened membrane and accumulated mucus. 
Its effect is not curative, of course, for the exudations are usually re- 
produced, and the former dyspnoea, with all its accompanying symp- 
toms, recurs. And yet, even when no membranes are expelled with 
the act of vomiting, temporary mitigation of the dyspnoea is never- 
theless observed in many instances, so that the act of vomiting seems 
to have a favorable influence upon the inflammatory swelling of the 
glottis itself. For the purpose of exciting vomiting once or twice, 
ipecacuanha answers sufliciently well. The more powerful doses of 
tart. emet. or of ciq). suljyh., that are given subsequently, it is true, 
produce more vomiting, but they seldom bring aboutany amelioration ; 
on the contrary, they lead to rapid collapse. The sweetened infusion 
of ipecacuanha, which children take without any objection, has the 
additional advantage that it much less frequently induces diarrhoea 
than those mineral salts. I generally give such an emetic once or twice 
as soon as I come to a case of developed croup, but regard it as use- 
less torture to nauseate the patients for any length of time after- 
ward. A most efllcient and prompt emetic is apomorphia, a solu- 
tion of which, containing one per cent, if injected hypodermically, 
will cause emesis. This remedy is especially useful in cases where 
there is difiiculty of deglutition, or inertia of the stomach, due to 
narcotic poisoning. For a long time sulphuret of potassium enjoyed 
the reputation of being a specific against croup, and seems to have 
become famous mainly through one of the Napoleonic prize competi- 
tors, who sent in his work anonymously, having recommended it as 
the only remedy for croup. But the ineffectualness of this remedy 
has become apparent in so many cases that it is now altogether 
abandoned. Its dose was one-half to one grain every hour. Next 
to the emetics, mercury was the most frequently-used remedy. Blue 
ointment was rubbed in upon the neck, over a larger or smaller sur- 
face of the thorax, and calomel was given in larger or smaller doses 
internally. When the peculiar action of mercurial preparations is 
desired to counteract the inflammation of the laryngeal mucous mem- 
brane, its use is rational, and the treatment is sustained by manifold 
analogies ; but, when calomel is given in large doses for the mere 
purpose of accomplishing a derivative action on the bowels, it is 
more injurious than the neutral salts, or small doses of drastic reme- 
dies. Of the few cases which I treated with mercury internally 
and externally, one recovered. That was a girl, five years of age, 
but in whom leeches and several emetics were also used, so that this 
result, as regards mercury, must be stated to be a very uncertain one. 



MIASMATIC DISEASES. 465 

The alkaline carbonates have been long recommended in croup, 
on account of their solvent properties, which they exercise over all 
animal substances, consequently also over croup-membranes. Sellweg^ 
Voss, Dorfmueller, JEggert^ Suf eland, and many others, have ex- 
pressed themselves in their favor, and, lately, X/uzsinshy, of Vienna, 
has appeared as a special advocate of carbonate of potassa. He gives 
two scruples, or one draclim, of this remedy in solution pro die, and 
ascribes to it specific effects. His therapeutic measures consist (1) 
in neutralizing the morbid admixture of the blood by the potas. carbon. ; 
(2) in overcoming the localization of the inflammation in the larynx, 
by a blister on the upper part of the sternum, kept in a state of con- 
stant suppuration ; (3) in moderating the dyspnoea and the cough- 
paroxysms by opium ; and (4) in cauterizing the existing membranes 
with nitrate of silver, and in causing their expulsion by emetics. 

Although I am unable to confirm the specific effects of carbonate 
of potassa — for, of five children which I treated very scrupulously ac- 
cording to Luzsinskifs method, I was only able to save one — still, this 
method of treatment has much advantage over the older method with 
leeches and emetics, for by it the children are not tortured, and, to say 
the least, just as many, and probably more, are saved by it. 

The other methods of treatment, with quinine, with large doses of 
narcotics, by the hydropathic method, etc., each of which has a suffi- 
cient number of advocates and detractors, I have not tried, and 
therefore refrain from giving any decided verdict upon them. 

The local treatment has already experienced manifold variations. 
Some wrap up the neck in dry, others in wet woollen cloths, or 
in moist sponges, or even in swallows' nests boiled in milk (a famous 
popular remedy). Others cause the neck to be coated with a layer 
of fat from all imaginable classes of animals, others again apply vari- 
ous counter-irritants, and still others maintain that the dysjjnoea is 
less severe when neck and breast are entirely uncovered. The French 
physicians always place great value upon Sretonneau's cauterizations 
of the larynx. For this purpose a proper whalebone rod, with a bit 
of sponge secured to one end, is made use of. The sponge is dipped 
in a solution of lunar caustic ( 3 ss — 3 j to water 3 j) and then intro- 
duced into the pharynx, the tongue being depressed with a spatula as 
much as possible. The sponge is allowed to tarry upon the epiglottis, 
and by a slight pressure some of the solution is squeezed out upon it. 
No special admonition is necessary about the corroding of the larynx, 
and the slipping of the sponge into the glottis between the chordaa 
vocales, because for this purpose a spontaneous deep inspiration is 
requisite, during which the epiglottis rises high upward, which is 
hardly possible vni\\ the sponge in the mouth. The solution of 



466 DISEASES OF CHILDREN. 

nitrate of silver has a decidedlj favorable effect upon the inflamed 
mucous membrane wherever it comes in contact with it, causing it, 
as a rule, to cast off its false membranes in the course of twenty- 
four hours, and thenceforth it often remains free from further 
formation. But in genuine fibrinous croup I have seen no effects 
whatever from the cauterization of the pharyngeal mucous membrane, 
which indeed is generally unimpaired. Besides the solution of lunar 
caustic, powdered alum, red precipitate (one part to twelve of sugar), 
sulphate of copper, and calomel, have also been blown into the pha- 
rynx. 

The air of the room in which these patients are confined should be 
pure and moist, and that is best secured by repeated ventilations, and 
by evaporating water in a shallow vessel. 

As a resume of what has already been said, I will here briefly no- 
tice the methods of cure advocated by the principal authors, without, 
however, committing myself to a belief in the efficiency of any indi- 
vidual remedy : 

(1.) Jurine. — In the first stage, abstraction of blood, according to 
the character of the attack and the state of the system ; after the first 
abstraction of blood, mild emetics, these to be continued in fractional 
doses during the second stage (in dyspnoea and suffocative attacks). 
Should the symptoms grow worse, sinapisms and blisters tipon the 
neck, breast, etc., and moist atmosphere to assist the inspiration. 
In the second period, emetics in full doses, and subsequently strong 
expectorants and antispasmodics, according to circumstances. 

(2.) Goells. — Leeches, calomel in large doses, inunction of ung. 
ciner. upon the neck and breast ; in the interval, oiitre y early vesica- 
tions ; in dyspnoea, emetics. 

(3.) Hufeland. — First his linctus emeticus (tart. emet. gr. j, ipe- 
cac, powder 3 j to § ijss mixture). Warm moisture, combined with 
saltpetre, and clysters of one tablespoonful of wine vinegar. When 
the dyspnoea becomes aggravated notwithstanding (just what actually 
occurs uniformly in genuine croup), sulphate of copper in emetic doses, 
in \ gr. doses every two hours, and so on at each exacerbation, inunc- 
tions of mercury on the neck, and counter-irritants. 

(4.) Luzsinsky. — The diagnosis having been determined, a blister 
at least the size of a silver dollar upon the manub. sterni. Internally 
sol. kali carbon. ( 3 j to water § iv), to be consumed in twenty-four 
hours. To cover the blister with epispastic paper and keep it suppu- 
rating as long as possible. In very severe dyspnoea, small doses of 
morphine ; an emetic during severe suffocative attacks. Cauterization 
of the pharynx with nitrate of silver. 

This last method, with the exception of the blistering, has the great 



MIASMATIC DISEASES. 467 

advantage of not torturing the patients, and therefore ought to be pre- 
ferred to all others. But if after repeated trials it should become mani- 
fest that it is totally inefficient, then it would be inhuman to continue 
it. As a natural result of the ineffectualness of those remedies hitherto 
used in croup, new ones will probably be constantly tried. 

Finally, a few words about tracheotomy. The idea of making a 
passage for the air through an opening in the trachea in persons who 
are about to suffocate from obstructions in the larynx, is very old, and 
as regards its practice in croup it is almost as old as the knowledge 
of croup itself, for Home pointed out this indication as early as 1765. 
Since that time, the operation has been performed from time to time, 
but always with unhappy results, so that the prize competitors of 1807 
could only mention one successful case, but that was a case in which 
the diagnosis is said to have been questionable. In 1823 Bretonneau 
again set the operation in motion, and since that time it has been con- 
stantly performed and defended by some of the French physicians ; but 
it is necessary to observe here, that the majority of the operations 
were performed in hospitals for children where contagious diphtheritis 
prevailed. WhUe many of these croup patients operated upon recov- 
ered, it is also true that recovery without tracheotomy often took place. 
Up to the year 1842, Trousseau had operated 119 times, and out of 
that number obtained 25 recoveries. At this time the principle was 
advanced that the operation must be performed very early, whereupon 
the ratio became so favorable that 14 recoveries occurred out of 24 
operations. According to another compilation, by Isamhert, 47 out of 
216 cases operated upon recovered, or 22 per cent. This doctrine 
loses much of its force by the circumstance that the operation must 
be performed so early in the disease that the practitioner, still less the 
surgeon, is unable to positively state if the case be one of croup or 
catarrhal laryngitis. In Germany, it is true, there are a few solitary 
advocates of the operation, Hoser and Passavant, for example ; but 
the majority of the physicians experienced in the treatment of the dis- 
eases of children, and also most of the German surgeons, do oiot per- 
form tracheotomy in croup. In England the opinion is generally 
against it, and in France a reaction seems to be rising up against it, 
for Boudmt ( Gazette Medicale^ 1858, No. 41) has shown that for every 
1,000 inhabitants in Paris, the number of deaths from croup increased 
from year to year, and was never so great as in the last decennium. 
In 1853 twice as many children died from croup as in 1837, and, from 
the years 1847-1858, on an average ^ve times as many as in 1838 ; 
while, according to a proximative calculation, no such increase of the 
disease as fivefold has occurred. He lays the blame of this great 
mortality directly upon the present local treatment, the escharotic, and 



468 DISEASES OF CHILDREN. 

tracheotomy. The reason why the operation has so Httle favor with 
us in Germany, and also in England, is, that we really have few diph- 
theritic, but mostly genuine fibrinous croup patients. 

The operation itself is not attended by any danger to life, and, 
according to Trousseau, is performed in the following manner : 

The child is laid upon the table, and under its shoulders a pillow 
is placed, supporting only the neck, so that the head may hang doAvn 
a little backwai'd, and the trachea be properly stretched. A longitudi- 
nal incision one and a half inches long is now made, commencing at 
the cricoid cartilage, and carried straight downward. The lips of the 
wound are retracted with blunt hooks, due attention being paid to 
the veins, which are also drawn aside by the blunt hooks. After the 
trachea has been suflBciently exposed, to an extent of three to four 
cartilages, which are recognized by their white appearance and greater 
resistance, a blunt-pointed bistoury, the dilator, and the double canula, 
especially made for tracheotomy, are then got ready. An incision is 
now made into the trachea, the opening is dilated, and the canula is 
then introduced by slipping it in between the separated branches of 
the dilator. After the operator has convinced himself that the air 
passes through the tube, the dilator may be removed, and the canula 
is secured by the aid of a tape, and the child, which has suddenly com- 
menced to breathe freely, is allowed to rise. 

Of the serious accidents liable to occm- during the operation. Trous- 
seau mentions, first of all, haemorrhage. Venous haemorrhage is con- 
trolled by simple compression \yith the finger, and ceases as soon as 
the canula is introduced ; arterial bleeding, of course, must be arrested 
by the ligature. The anxiety about the blood finding its way into the 
trachea, on the whole, seems to be somewhat exaggerated, since in 
patients Avith haemoptysis a certain quantity of blood necessarily must 
remain in the trachea and bronchi, but it generally does not induce any 
particular sufi"ocative attacks. 

Syncope very fi-equently occurs after the operation, and is produced 
by the sudden disturbance of the cerebral circulation, in consequence 
of the respiration having suddenly become free. Trousseau once saw 
it last one hour, but never terminate fatally. 

If the respiration does not improve after the operation, the canula 
will be found to be blocked up with blood coagulge or pseudo-mem- 
branes, wliich must be removed by means of a forceps made for that 
purpose. 

In the after-treatment, the greatest attention is to be bestowed 
upon the canula. The wound should be covered with a piece of oiled 
silk, with a hole in the centre to admit the tube ; a second canula is in* 



MIASMATIC DISEASES. 469 

troduced into the first, so that, for the ptirpose of cleansing', the whole 
apparatus need not be removed ; and a thin cloth is tied around the 
neck, in order that the air may not come directly in contact with the 
tracheal mucous membrane, but first be purified from dust by passing 
through the cloth. The canula should be taken out every three or 
four hours and cleansed. Once only Trousseau was able to remove 
the canula permanently on the fovirth day, several times on the sixth 
and eighth, generally between the tenth and thirteenth, once not till 
the forty-second, and once after the fifty-third day. No tracheal fistula 
ever resulted from the o.peration. 

Children eat and drink immediately after the operation, and 
without any difficulty. Four or five days later, however, a spasmodic 
cough comes on every time drink is taken, and part of the liquid 
is expelled through the canula, a proof that the epiglottis is not able 
to perform its functions as thoroughly as in the normal state. This 
condition lasts one or two weeks and then subsides. In serious sufib- 
cative attacks. Trousseau forbids all liquid nutriments. 

So much about the execution of this most unfavorable of all oper- 
ations, which I, for my part, never insist upon, nor directly oppose 
when proposed by other physicians, and still less by the parents them- 
selves. 

Let us assume that all the children operated on had genuine croup, 
the ratio of recoveries of twenty-two per cent, is nevertheless an ex- 
tremely unfavorable one, and especially since the greater portion of the 
children operated on sufiered from the milder diphtheritic form. And 
if we take into consideration the additional fact that the majority of 
physicians experienced in children's diseases have abandoned the oper- 
ation in croup, on the ground that it is a general disease, with locali- 
zation upon the larynx, we must, it appears to me, discourage its prac- 
tice generally, and close with the following words from old Goelis : " Ad 
tracheotomiam, omnium remediorum incertissimum confugere res ardua 
est ; parentes abhorrent, aversantur agnati et periclitatur medici fama, 
quern, infausta si fuerit operatio ac votis illudens, lacrymis multis velut 
homicidam prolis amatae detestantur parentes." 

PATHOLOGY OF DIPHTHERIA AND CROUP. 

[In order to complete the subject of the pathology of these two 
diseases, we append an abstract of the anatomical differences be- 
tween them according to jE Wagner, from the Archiv der Heil- 
'kunde, 18G7. 

The author defines dipbthei'ia to be that affection of the mucous 
31 



470 DISEASES OF CHILDREN. 

membrane in which it is more or less infiltrated, and thickened, and 
covered by a grayish membrane which adheres to it closely. In 
croup, on the contrary, the mucous membrane appears to the naked 
eye nearly normal or simply hyperaemiated and lined by a slightly ad- 
herent membrane. 

The diphtheritic membrane of the pharynx and velum palati pre- 
sents itself under the microscope as a clear homogeneous net-work, 
whose rounded, elongated, or irregular meshes are sometimes emptv, 
sometimes filled with diverse elements (lymphatic or purulent glob- 
ules ; sometimes red globules or elements of indistinct cellular or nu- 
clear nature). The trabeculae which circumscribe the meshes of this 
net-work are habitually pretty thick, especially in the pharynx, while 
in laryngeal diphtheritis they are much more delicate. In the deep 
parts of the membrane the lymphatic globules are much more numer- 
ous, while on its surface are found still in a fresh state pavement 
epithelial cells, as they exist normally in the upper layers of the epi- 
dermis and mucous membrane. The limit between ihe deep part of 
the false membrane and the mucous membrane is always neatly de- 
fined, which, however, does not prevent their intimate adhesion. 

The formation of the diphtheritic net-work is followed with diffi- 
culty. However, from comparing diiferent preparations it is easy to 
convince one's self that it takes the place of the epithelium, and that 
it forms itself in reality by a special metamorphosis of the deeper 
cells, and never the superficial pavement epithelium cells ; this meta- 
morphosis presents three stages. The first stage consists in an aug- 
mentation of volume of the cells in all their diameters ; which acts 
rather upon the protoplasma than upon the nucleus. In the second 
stage the protoplasma of the cells undergoes a peculiar transforma- 
tion ; at the peripheric part of the cell appear clear spaces augment- 
ing gradually in volume and impinging on the cellular contents, which 
then appears as it were excavated ; at the same time it becomes 
deeper and more refringent, and presents a great resistance to all ordi- 
nary microscopic reagents. The third stage is characterized by the 
continuation of this process, and the complete disappearance of 
the nucleus of the cell. Each cell is then replaced by a reticulated 
formation perforated with holes, the prolongations of which are united 
to the prolongations of the neighboring cells to constitute the netr 
work of the diphtheritic membrane. 

The reticulated substance of the diphtheritic membrane and those 
of croup are not essentially distinguishable from each other in a 
chemical point of view. They closely approximate to co.agulated 
fibrine. The diphtheritic net-work possesses a remarkable inaltera- 
bility for chemical or ordinary reagents. 



MIASMATIC DISEASES. 4,71 

The modification of the mucous membrane itself consists in a new 
formation of cells and nuclei, sometimes in small quantities and some- 
times in so great a number that the process takes the character of 
an intense purulent infiltration. True abscesses are seldom found. 
The blood-vessels are enlarged and filled with white globules. In 
most cases small haemorrhages are met with, and in some cases a con- 
siderable infiltration of red globules. The submucous tissue, the inter- 
glandular connective tissue, and the intermuscular tissue, may also be 
the seat of infiltration. 

The mucous glands take no essential part in diphtheria. 

The eroupal membrane consists in a close net-work of fine fibrillae, 
whose meshes contain a great quantity of elements resembling puru- 
lent globules. Here and there this net-work recalls to mind the neu- 
roglia of the cortical substance of the brain. The globules enclosed 
in the meshes of this net-work are much more numerous than those 
in diphtheria. The formation of eroupal membrane is followed with 
much more difficulty than that of the diphtheritic. The mode of 
formation, however, is identical in the two cases ; only in croup the 
greater fineness of the net-work is due to the much more active pro- 
duction of globular elements in the interior of the epithelial cells, 
while in diphtheritis the production of globular elements is very lim- 
ited. The slight adhesion which exists between the eroupal mem- 
brane and the surface of the mucous membrane is due to the inter- 
position of a thin layer of muco-purulent liquid which separates 
them. On examination this liquid shows purulent globules, some- 
times cylindrical epithelial scales with or without vibratile cilia, and 
some red globules. The very tissue of the mucous membrane is more 
or less hyperaemiated. In the large and middle-size bronchi the dis- 
position is the same. 

While diphtheria, in fatal cases, shows itself in the pharynx, croup 
in the lower portion of the larynx and trachea, the upper part of the 
larynx presents sometimes the diphtheritic membrane, and sometimes 
(though more rarely) the eroupal membrane ; sometimes, again, there 
is a combination of these two affections. The latter case is the more 
frequent. Under the microscope the net-work of the pathological mem- 
brane is ordinarily finer than in the pharynx, but thicker than in the 
trachea. 

The author groups the cases which he has observed under the fol- 
lowing heads : 1. Primitive croup of the pharynx, without coincident 
or consecutive affection of the larj^nx. 2. Ditto, with consecutive 
croup of the larynx and trachea. 3. Primitive croup of the larynx and 
trachea, without croup of the pharynx. 4 and 5. Primitive diphtheri- 
tis of the phar^Tix, with or without participation of the air-passages. 



472 DISEASES OF CHILDREN. 

Tlie author has observed the following combinations : a. Diphthe- 
ritis of the whole larjnx, of the whole trachea, and large bronchi ; 
croup of the medium bronchi. b. Diphtheritis of the larynx and 
upper part of the trachea ; croup of the rest of the trachea and 
bronchi, c. Diphtheria of the epiglottis and upper part of the 
larynx ; croup of the lower part of the larynx and trachea, with or 
without croup of the bronchi. Most of the cases of croup which he 
had occasion to see in children belonged to this category. 

A single case in a child of eleven years of age, of primitive diph- 
theritis of the larynx and trachea, the pharynx being entirely natiwal, 
has been observed. 

The author concludes, from the anatomical and pathological facts, 
that there is no defined limit between croup and diphtheritis. We 
meet equally in the pharynx, as in the air-passages, pure croup and 
pure diphtheria. Only in fatal cases diphtheritis affects preferably the 
pharynx, croup the lower part of the larynx, trachea, and bronchi, 
while the upper part of the larynx offers a combination of the two 
affections, or rather an intermediate form. 

Supplementary to the treatment recommended by the author in 
the text, we subjoin the following as important addenda to the 
therapeusis of this formidable disease : 

In the local treatment of croup Weber uses lactic acid by inhala- 
tion, for the pinrpose of causing the membrane to dissolve. At first 
he used it only after the operation of tracheotomy, partly with a view 
to keep the tracheotomy-tubes clean, and partly hoping that the lactic 
acid mie-ht affect the false membranes which extended downward into 
the bronchi. The results were so favorable in both respects that he 
proceeded to try it in severe cases of croup before resorting to trache- 
otomy. Since then he has not once had occasion to operate, and has 
not lost a single case of croup. In some very severe cases in which 
inspiration and expiration were equally obstructed, and the condition 
of the fauces indicated an abundant fibrinous exudation in the trachea, 
the difficulty of breathing was completely relieved within seven to 
ten hours of using this remedy, and two or three days after no trace 
of the local affection remained. 

During the treatment there was not, as is generally the case, 
tough membranous sputa, but gradually the whistling, barking in- 
spiration and expiration were replaced by distinct rattling noises ; 
the voice, before quite suppressed, began to assume a hoarse char- 
acter, and considerable quantities of tough, loose phlegm were ex- 
pectorated during the fits of coughing, until at last the struggle for 



MIASMATIC DISEASES. 473 

breatli quite ceased, and the disease assumed more the character of a 
catarrhal aflfection of the throat. 

The treatment consists in the local application of the remedy to 
the windpipe by means of inhalation. The patient is made to inhale 
a solution of lactic acid (fifteen to twenty drops in half an ounce of 
water), at first every half-hour, and afterward when the respiration 
improves, every hour, or every two hours, a solution of ten to fifteen 
drops in half an ounce of water. 

The solution is discontinued as soon as the dyspnoea has subsided, 
and to promote expectoration camomile-tea is exhibited. 

In using the inhalation care must be taken that the vapor does 
not affect the face and eyes. 

With this treatment was conjoined the internal exhibition of car- 
bonate of soda every half-hour or every hour, which w^as thought to 
exert a beneficial effect upon the exudation. 

In diphtheritis Hothe employs a solution of carbolic acid, as in the 
following formula : 

5 • Acidi earbolici cryst. 

Spiritus vini as 3j — 3ij. 
Aquadestillatse 3v. 
Tinct. iodinii 3j. 
M. et slg. Brush the solution over the false membrane three times daily. 

In addition, the patient is made to gargle the throat every fifteen 
minutes with ten or fifteen drops of the mixture in a large cupful of 
warm water ; at the same time digitalis, for the fever, and tinct. ferri 
chlorid. are administered. By this treatment Rothe claims to have 
saved fourteen out of fifteen cases of undoubted diphtheria. 

Dr. Albu, Director of the Lazarus Hospital at Berlin, in laryngeal 
croup, injects lukewarm lime-water into the larynx by means of a 
syringe and canula after tracheotomy. The injection causes violent 
coughing, during which shreds of diphtheritic membrane are also ex- 
pelled. The treatment of diphtheritic croup by injections of lime- 
water is also indorsed by Gottestein and Waldenburg. 

In the New-York Medical Journal for July, 1870, after a 
brief review of the pathology, prognosis, and diagnosis of croup. Dr. 
JBurrje, of Brooklyn, N. Y., gives the following as the result of his own 
experience in the form of propositions : 

" Proposition VI, If the stomach be full, or indigestible food have 
been recently taken, a single emetic may be given. Proposition VII. 
Give a dose of bromide of potassium to quiet all spasmodic ac- 
tion, four to twenty grains, and repeat every six hours. Proposition 
VIII. Give one-half to one teaspoonful of liq. calcis ever}' hour or 



474 DISEASES OF CHILDREN. 

every half-hour. Proposition IX Allow the patient to inhale the 
vapor of slacking lime. The lime to be slacked in an open pail or 
tube. If the patient resist violently, the lime may be freely slacked 
in the room to such an extent as to keep the air constantly moist. 
Proposition X. Take equal parts of impure carbolic acid and glycerine, 
pour upon a teaspqonful of this mixture, in an open basin, a pint of 
boiling water. Renew this every four hours, and allow the patient to 
inhale the vapor for a few minutes. Let the preparation stand in the 
room till renewed. Proposition XI. Give an enema of strong hop-tea 
at least twice a day. If the child be costive, add to the first enema 
one or two teaspoonfuls of table-salt. Proposition XII. Use ex- 
ternally some gently-stimulating and anodyne liniment ; say, liniment, 
saponis (shghtly ammoniated) 3 ii, tr. aconite rad. | ss. Apply this 
with a camel's-hair pencil to the neck. Let the diet in nursing 
children be the breast-milk ; in older ones give meat-broth, milk, or 
wine-whey and water ad libitum. Proposition XIV. As a general 
rule, he is opposed to topical applications. Proposition XV. Trache- 
otomy is unjustifiable except as a dernier ressort, and even then it is 
a forlorn hope." 

Dr. JFablus, of Amsterdam, in the Journal fur Kmderheilkunde^ 
has an article on the treatment of croup. He is opposed to debili- 
tating remedies. Of late years he has ceased to bleed in croup, and 
been more successful than formerly. An emetic, a warm poultice to 
the neck, and a large quantity of steam in the room, are useful pre- 
liminary measures. If false membrane has actually formed, he objects 
to antimony, as a frequent cause of sudden death in young children ; 
to sulphate of copper and chlorate of potassa. He ascribes more 
efficacy to carbonate of potassa, with which Letizsinshj, of Vienna, 
saved seventy-five per cent, of pure croup, and to which Vogel, of 
Dorpat, gives the preference over all remedies. It should be used in 
doses of 3 ss to 3 ij, daily, diluted with water; it is not debihtating 
nor dangerous ; it is the carbonate^ and not the bicarbonate, which is 
recommended. Emetics, poultices, steam, and carbonate of potassa, 
are his remedies until tracheotomy becomes needful. This is to be 
performed when the disease is becoming worse, and the difficulty of 
breathing greater ; when the anxious expression of the face begins to 
be permanent, and cannot be removed by emetics ; when the scro- 
biculus cordis, and the region above the clavicles, are drawn in upon 
inspiration ; when, finally, double pneumonia is not present, nor any 
other inevitably fatal condition, and when the strength is not too far 
gone, tracheotomy should be performed, with a care like that required 
in making an anatomical preparation. 



MIASMATIC DISEASES. 4Y5 

Prof. Fordyce Barker^ of this city, in an unusually interesting ar- 
ticle, contributed to the May number of the Atnerican Jotirnal of 
Obstetrics, after expressing the opinion that false and true croup are 
identical in nature and seat, but diifer only as to intensity and extent 
of tissue involved, and premising that what he has to say on the 
treatment of croup will have no reference to the treatment of diph- 
theria, and that success depends in a great measure on the use of 
efficient remedies in the very commencement of the attack, proceeds 
as follows : " I always commence the treatment by an emetic of tur- 
peth mineral (hydrarg. sulphas flava), in doses of from three to five 
grains, according to the age of the child ; repeating it in fifteen minutes 
if it does not act ; which, however, is rarely necessary. It is prompt, 
efficient, tasteless, and easily administered, and does not exhaust and 
depress the vital powers like antimony." He regards it as very im- 
portant that this emetic should be given immediately on the appear- 
ance of the symptoms which threaten croup ; carries it constantly in 
his pocket ; and has it kept in all families with young children which 
he attends, where the slightest tendency to catarrhal laryngitis has 
been manifested. After this, if he finds the evidence of catarrhal 
laryngitis simply, he relies mainly upon opiates, which he regards as 
almost the specific for acute catarrh of the respiratory apparatus, 
whether it occurs in infantile or adult life. If, however, he finds the 
child with a quick pulse, hot skin, somewhat hurried breathing, and 
an occasional ringing cough, but with no thoracic rales, he directs that 
it should be kept quiet in bed, comfortably covered, and prescribes 
the veratrum viridi, in one or two drop doses, according to the age 
of the child, every two hours, until the pulse is below 80 per minute, 
and then continues the veratrum in half the dose he found necessary 
to bring it down to that point. If thoracic rales and other symptoms 
indicate that the disease is extending downward, he then combines 
the veratrum in a mucilaginous mixture with carbonate of ammonia, 
giving it every second hour. He has, occasionally, in cases of in- 
creasing laryngeal and tracheal obstruction, repeated the emetic of 
turpeth mineral on the second or third day, but never the third time. 
Several times, a few hours after the emetic, but never during its im- 
mediate operation, the child has thrown off more or less detached 
portions of membrane ; in two instances, perfect casts of the trachea 
with its bifurcation, and some of the primary branches of the bronchi. 
In some cases of croup, in the advanced stages, when the respiration 
is hurried and irregular, paroxysms of cough less marked, the inter- 
missions less distinct, and the cough husky instead of ringing, he com- 
bines with the carbonate of ammonia the sulphate of quinine in two- 
grain doses. When the croup is complicated with lobular pneumonia, 



476 DISEASES OF CniLDREX. 

he usually gives the quinine separately, four to five grains three 
times a day, while the patient takes the last of the prescriptions 
containing veratruna viridi. During the twenty years Dr. Barker 
has practised in this city, he has never lost a case from croup. 

[Finally, Dr. Jacobi has proposed and uses the bichloride of mer- 
cury in the treatment of diphtheritic croup as a germicide, giving 
it in small doses frequently repeated. I have had no experience 
with this preparation of mercury in the treatment of this disease, 
but twice it was my good fortune to save children from imminent 
death by administering large doses of calomel. In each ease I ad- 
ministered twenty-grain doses, repeating the dose two hours after- 
ward with the happiest result. Both children recovered. I must, 
however, confess that the remedy similarly administered has failed 
utterly in other cases.] 

(3.) DiPHTHEEITIS AND GaNGREXE OF THE FeMALE GeNITAXS. 

— Diphtheria rarely if ever occurs sporadically, but only in badly- 
ventilated hospitals, foundling-houses, and orphan asylums. In this 
country it is in general rare, and is most frequently encountered 
during and after malignant epidemics of measles, when it also comes 
on in the overfilled, damp tenement-houses. Diphtheritis is no local, 
but a general disease, as has been already elucidated in the chapter 
on Diphtheria, and as is seen from the fever, rapid collapse, and 
generally fatal termination. 

The disease begins like simple fluor albus, with redness and 
swelling of the vulva, but violent fever, hot skin, frequent pulse, 
and increasing thirst, soon supervene. If the labia majora are now 
separated, the mucous membrane will be seen covered with islands 
of white membrane. In shape they are sometimes circular, some- 
times again very irregular, from the coalescence of several islands. 
At first it is not easy to remove them ; they, however, soon disin- 
tegrate into shreds, and leave behind them yellowish-gray bases, 
upon which, after the first shreds have fallen off, new membranous 
exudations quickly appear. The parts of the mucous membrane 
free from these exudations are tumid, and of a dirty-red color. The 
odor of the sanious discharge is very offensive and persistent. The 
general state of the system indicates a grave disease, the fever 
assumes a typhous character, the ichor finally emits a gangrenous 
odor, the false membranes and the subjacent tissues also become 
gangrenous, and death ensues in a few days from the commence- 
ment of the disease. 

Gangrene of the vulva is caused either by diphtheria, or comes 
on like noma, in children who have just passed through a severe 
febrile disease, such as typhus fever, small-pox, scarlatina, or measles. 



MIASMATIC DISEASES. 4Y7 

Sometimes it comes on so rapidly, and without any subjective symp- 
toms, that the attention of the relatives is first attracted by the 
gangrenous odor. This leads to a careful examination, when a few 
gangrenous vesicles, as a rule, are found upon the internal surfaces 
of the labia majora, which soon burst and give exit to a gangrenous 
ichor. In other instances, where the mortification has invaded the 
deeper structures of the labia, the latter will become (Edematous, 
assume a bluish color after the pains have existed for several days, 
and finally burst, when a large gangrenous surface will make its 
appearance. The mortification is mostly moist, spreads rapidly, and 
ultimately terminates in death. Besides the local destructions, ca- 
tarrh of the mucous membrane of the air-passages, and frequently 
also pysemic emboli in the lungs, spleen, etc., are found in the 
cadaver. 

Therapeutics. — The treatment of these serious diseases is very 
unsatisfactory. Internally, carbonate of potassa ( 3 j daily) is recom- 
mended as a specific in the diphtheritis ; usually, however, the fatal 
end cannot be averted even by this remedy. The stimulating treat- 
ment should be resorted to as early as possible, especially in gan- 
grene. Topically, the parts should be pencilled with concentrated 
mineral acids, or a strong solution of corrosive sublimate. The lat- 
ter exercises a marked favorable effect upon the diphtheria, though 
in gangrene it has invariably proved inert in all those cases that I 
have observed. 

(4.) Typhus Fever {Typhus Ahdominalis, Nerven-, Schleim- 
Fieher, Ileo-Typhiis). — Abdominal typhus is much more frequent 
in children than is commonly suj^posed, but the diagnosis in 
many cases cannot be made with certainty, and, on this account, 
many physicians attribute to children great resistance against 
this disease. Their liability to infection, if such can be assumed, 
is an extremely small one, and is not at all to be compared with 
the other infectious diseases, measles, scarlatina, and pertussis. 
While it often happens that the children of several families in one 
house are simultaneously attacked by typhus fever, usually of a 
mild form, still it more frequently occurs that only one child out 
of a numerous family is seen to fall sick with it, all the rest 
remaining well, although all have occupied the same room, and 
none of them have been protected by previous fever. Typhus 
fever is extremely rare in children before the completion of the 
first year of life ; still, individual cases are found recorded of 
nurslings who perished by this disease, but it is observed that no 
typhous intestinal ulcerations, &\vl\\)\j infiltration of Peyer's patches 
and of the mesenteric glands, are spoken of in the reports of the 



478 DISEASES OF CHILDREX. 

post-mortem examinations afforded by these cases. In the second 
year of life, and after the completion of the dentition in the third 
year, abdominal typhus becomes extremely frequent, and is attended 
by tolerably characteristic symptoms, and from this age onward it 
may occur at any age and at any season of the year. 

As the plan of this treatise presupposes a thorough knowledge 
of special pathology and therapeutics derived from other sources, 
only the deviations peculiar to the infantile age can properly come 
within its scope. Nor does a critical examination of the present 
prevailing opinions regarding contagious diseases, and the connec- 
tion of the local with the general affection, belong to it. But this 
much must be said in this connection : (1.) That the conditions 
found in the alimentary canal do not stand in exact relation to the 
general disease ; and (2.) That no qualitative nor quantitative al- 
terations have ever yet been found in the blood of typhous patients. 
The changes in the blood of typhous patients, who have been ill for 
many weeks, are the effects of protracted disturbances in the textural 
metamorphosis, and of the circulation ; and the so-called typhous 
blood, by which a dark, violet-colored liquid blood, with soft, loose 
coagulae, is understood, is not invariably found in the typhus cada- 
vers, but yet in the cadavers of most patients whose diseases were 
combined with disturbances of respiration and assimilation. 

Post-mortem Appearances. — In general, a first and a second pe- 
riod can be distinguished in the typhus corpse. 

If death takes place in the first period, the typhous morbid changes 
will only be found in the small intestines, in the mesenteric glands, 
in the spleen, and upon the bronchial mucous membrane. The cada- 
vers are not emaciated, have deep-blue j:)ost-mortem spots, and the 
muscles are dry and dark-colored. The brain is firm and dry. The 
bronchial mucous membrane is reddened, swollen, and everywhere 
coated with a tenacious, yellowish-white mucus, so that in some 
places the bronchi of the third order are completely filled up with it. 
The infallible consequences of this overfilling of the bronchi with 
mucus, especially posteriorly and inferiorly, are disturbances of cir- 
culation in the pulmonary organs, hypostasis, and ultimately spleni- 
zation. The heart is extremely feeble, contains very loose coagulse, 
and its muscular structure at some places is blanched. These pale 
spots exhibit, under the microscope, commencing fatty degeneration. 
The spleen is enlarged, and the enlargement affects particularly its 
long diameter. Its capsule is tensely distended, its structure very 
dark and soft, and often of a semi-fluid consistency. 

The abdomen is distended, the bowels are tympanitic, and con- 
tain a large quantity of intensely-offensive fluid ; almost the whole 



MIASMATIC DISEASES. 4Y9 

mucous membrane of the small intestines is in a state of acute 
catarrh, and Peyer's patches, as well as the solitary follicles, are 
markedly infiltrated. The hypertrophy of the glands just mentioned 
is produced by a deposit of a grayish- white medullary mass, which 
principally fills up and swells the capsule of the glands, but involves 
also the submucous and even the mucous tissue itself. The mor- 
. bid changes and course of these infiltrations in children deviate 
somewhat from those observed in the adult. While the great ma- 
jority of typhus cadavers of the adult display ulceration of the 
glandular patches, in children this is only an exceptional occur- 
rence, for the infiltration, in most of these cases, seems to undergo a 
retrogi'ade metamorphosis, or at least a simple bursting of the cap- 
sule and evacuation of its contents without any cicatrization. Al- 
though, in rare instances, true cicatrization or ulceration has been 
found, they are nevertheless but isolated instances in which one or 
more patches only have been implicated. The majority of Peyer's 
patches always stop at the stage of the brain-like infiltration, and this, 
in fact, also explains the reason why intestinal haemorrhage and per- 
forations are so extraordinarily rare in children. The younger the 
child, the less frequently are ulcerations met with. I have never yet 
found them in children under four years, although I have dissected 
many children, of from two to four years of age, which died from 
undoubted typhus fever. 

The mesenteric glands become affected in exactly the same man- 
ner as Peyer's patches. They enlarge to three or four times their 
normal size, and, when cut into, are seen to be yellowish gray and 
brain-like. Their size appears to depend upon the amount of infil- 
trating material deposited into them ; Peyer's patches are to be 
found opposite the ileocaecal valve ; so also the mesenteric glands 
opposite this valve are most hypertrophied. 

If the cadaver of a child which died in the second stage be dis- 
sected, the first thing that will attract the attention is the exti-eme 
emaciation. The skin is pale and flabby, the post-morte^n spots are 
not so intensely violet, the muscular system is pale and (Edematous, 
and infiltrated with serum. The integument often exhibits bed-sores, 
pustules, sudamina, and ecchymosis ; sometimes the lower extremities 
are somewhat dropsical. The parotid gland may be swollen and 
permeated by purulent sinuses. Perichondritis and necrosis of some 
of the laryngeal cartilages are sometimes observed in the larynx ; 
the lungs reveal a still greater amount of splenization than in the 
first period, and the bronchi are filled with mucus. The spleen is 
swollen and corrugated, the mesenteric glands are enlarged, and ab- 
scesses are sometimes formed in them. Peyer's patches and the 



480 DISEASES OF CHILDREN. 

solitary follicles are slightly tinged with a grayish pigment ; the 
capsules are mostly ruptured, giving the whole glandular surface a 
reticulated appearance ; and when, in older children, solitary ulcera- 
tions have occurred, they will be seen undergoing cicatrization. If 
the children have succumbed to pyaemia, the well-known purulent 
exudations and embolic formations will be found in the serous sacs 
and parenchymatous organs. If they have perished from anaemia and 
scorbutus, marked serous effusions into the cavities of the body and 
in the subcutaneous tissues will be found. In scorbutis the morbid 
condition of the gums will have become superadded. The brain, in 
contrast to the first period, is extremely moist and soft, and is with 
difficulty removed entire from the cranial cavity. The rarity with 
which ulcerations of Peyer's patches occur makes it easy to confound 
this pathological condition with that found in enteritis folliculosa. 
But the hypertrophy of the spleen and the state of the lungs are 
sufficient to distinguish typhus fever from follicular enteritis. 

Symptoms.— As may already be inferred from the description of 
the post-mortem appearances, the morbid alterations and destruction 
which typhus fever brings about in the infantile organism are not 
so decided as in the adult ; and, correspondingly, the symptoms are 
usually also less intense and threatening, and the prognosis in gen- 
eral favorable. The symptoms are seldom so violent and character- 
istic that the diagnosis of typhus fever may be formed with certainty 
at first sight, as an experienced observer may usually do when he 
approaches the bedside of an adult patient seriously sick with it. 
The diagnosis is very liable to vacillate between typhus fever and 
acute hydrocephalus, and upon this difficulty in the differential diag- 
nosis many of the recoveries from supposed acute hydrocephalus rest. 
In most of the cases, however, children have so mild a form of 
typhus fever, that it is confounded with gastrocismus or dentition 
trouble, and consequently less apprehensive parents do not seek any 
medical assistance at all. Physical diagnosis furnishes little, if any, 
aid in this mild typhus fever of children. The spleen does not become 
materially enlarged, the abdomen is not much distended by gas, and 
the bronchial catarrh attains to no alarming degree. The diarrhoea 
is moderate, the children are quiet, do not complain of pain, and 
sleep a great deal. The marked and protracted lassitude, the contin- 
ued loss of appetite, and the tedious convalescence, during which the 
hair always falls out, and is at first replaced by a thinner, lanugo-like 
crop, are the most characteristic symptoms of a lingering febris ty- 
phoides, which in Munich is popularly called " mucous fever." 

Yet it cannot be denied that individual children, especially after 
they have completed the first dentition, may display very severe and 



MIASMATIC DISEASES. 4gl 

complete symptoms of typhus fever, and it is therefore necessary to 
subject them to a special analysis. 

First of all, as regards the chronology^ there is no acute disease in 
which it is so difficult to decide the period of invasion as in typhus 
fever ; nevertheless, this is usually easier in children than in adults, 
since their tenderer organism is much more violently disturbed by 
an infection, and its commencing action. And, besides, they are 
neither compelled by necessity nor occupation to struggle against 
the disease as long as possible, notwithstanding its growing severity, 
and therefore their early symptoms are unmodified. The day on 
which the child loses its accustomed spirits, and lies down and falls 
asleep at unusual hours, when followed by the more characteristic 
symptoms, is to be regarded as the commencement of typhus fever. 
The child sometimes retains its appetite up to the same day, but usu- 
ally it vomits the whole undigested meal at the end of a few hours, 
when the symptoms of typhus fever, as a rule, come on quicker and 
are severer than when no vomiting has taken place. I have never 
observed any distinct chills, and consequently can place no value upon 
them in deciding the day of invasion. When typhus fever develops 
itself during dentition, it will scai'cely be possible to decide its com- 
mencing period, for here the almost physiological diarrhoeas and con- 
gestions of the head merge very insidiously into the typhous symp- 
toms. Typhus fever in children may, as respects its duration, run a 
course as irregular as it does in the adult, and therefore no definite con- 
clusion can be formed, as to its course and duration, from the violent 
appearance of the first symptoms. Some children recover more quick- 
ly from an intense typhus fever than others do from a very mild, lin- 
gering f ebris typhoides. In general, however, it may be assumed that 
a child, which has recovered completely in less than three weeks 
without marked emaciation, has had no typhus fever, nor even a 
febris typhoides, because children affected by those diseases are re- 
tarded in their development and nutrition for more than three weeks. 

The extent of febrile phenomena in children cannot be so readily 
expressed as in the adult, such as the pulse, temperature of the skin, 
and the amount of urine excreted. The restlessness of a typhous 
child interferes with the use of the thermometer to determine 
the temperature of its skin, because, as is well known, the instru- 
ment must be entirely surrounded by integument, and allowed to 
lie quietly for from fifteen to twenty minutes. It is, therefore, bet- 
ter to observe the warmth of the forehead, trunk, and extremities, 
with the hand previously wanned, no matter under what disease be 
may be laboring, and this kind of examination, practised a few hun- 
dred times, gives such an ajnount of skill, in distinguishing the dif- 
ferent degrees of temperature, that therraometric measurements, 



482 DISEASES OF CHILDREN. 

always requiring a certain amount of time, and often totally impos- 
sible, will be entirely unnecessary for any practical purpose. 

[Nevertheless, for the purpose of accuracy and record, it is best 
to employ the thermometer to designate the progress of the disease. 
This much may be said here, that a temperature of 10.5° Fahr. does 
not indicate an entirely hopeless condition. The therraometric meas- 
urements, together with the secretions of the kidneys and condition 
of the pulse, form highly useful data in the prognosis and treat- 
ment of the disease.] 

As to the pulse, upon whose condition and frequency in adults so 
great a value is justly placed, it gives less positive indications in chil- 
dren. It is always extremely rapid, up to 160 and 170 beats in the 
minute without being attended by corresponding danger, or render- 
ing the prognosis particularly unfavorable. During convalescence 
it may be compressed with the utmost ease ; in the mortal agonies 
it becomes uncountable and imperceptible. An intermittent pulse 
seldom occurs in children, and I do not remember to have ever met 
with a dicrotic pulse in children under ten years of age. 

Of the subjective febrile symptoms, the prostration, the excitabil- 
ity, and the lethargy, are always the most important. Very seldom 
do children suffer any decided chills ; the head is always flushed, the 
eye heavy, and in patients greatly excited presents a peculiarly glisten- 
ing appearance. The expression of the face is either that of apathy 
or of great excitability, or, in the most violent cases, of confusion. 

Very soon the asshnilative functions assume an extremely unfavor- 
able condition. The loss of appetite, and the uncontrollable, profuse 
diarrhoeas on the one hand, and the urine, rich in excretive material, 
on the other, explain sufficiently the rapid emaciation of typhous chil- 
dren. I have often endeavored to extend, in the case of children, my 
investigations of the urinary substances, which, for years, I have carried 
out on a very extensive scale in adults. But all my efforts foundered 
on the impossibility of obtaining the urine which children under ten 
years of age pass in the twenty-four hours. Isolated opportunities for 
the investigations of the urine always showed in typhous children 2.5 to 
3.5 per cent, of solids. As, judging by the eye, they pass a tolerably 
large amount of urine, it may be fairly inferred that, in typhus fever, 
children, as well as adults, lose a large quantity of urinary solids. It 
is a remarkable fact that the emaciation progresses and only attains 
its climax when the appetite has already fully returned and the pa- 
tients are steadily convalescing. If sequelae, such as tuberculosis, 
scorbutis, phlebitis, in various cutaneous veins, or large abscesses, su- 
pervene, the cliild will often be reduced to a mere skeleton, but 
the prognosis need not on that account necessarily be assumed as ab- 
solutely desperate, for such children occasionally manifest a wonder- 



MIASMATIC DISEASES. 4g3 

ful resisting power, and finally, after manj months, recover. After 
every intense typhus fever, children lose their hair almost completely. 
It returns slowly, first very thin and lustreless ; ultimately, however, 
it grows stronger, acquires its original color and fulness. In the usual 
milder forms, in which the prevailing typhous symptoms are only im- 
perfectly developed, the falling out of the hair is less marked. 

The most important alterations always take place in the digestive 
system. Anorexia is one of the most constant symptoms, usually 
complete, but sometimes attended by peculiar longings, such as for 
rye-bread, fruit, etc., articles which, in fact, may be allowed the child 
without any great danger, so long as the precaution is taken not 
to indulge it vsdth too large quantities at a time. Generally it plays 
with the food placed before it, carrying a little to the mouth from 
time to time, but, in most instances, does not swallow even that, but 
spits it out again, and so the craving for food is appeased. The ano- 
rexia lasts as long as the febrile symptoms continue, during which 
time the greatest difficulty will be experienced in supporting the 
children in any manner, fluid food being almost exclusively available. 
After a while the appetite returns, and in a few days becomes a rav- 
enous hunger, the indiscreet gratification of which often causes serious 
relapses. 

In children the tongue seldom becomes as dry as in the adult, be- 
cause they almost always sleep with the mouth shut, and thus the main 
cause of the dryness of the tongue is wanting. In most instances it 
is rather thickly coated, and the papillee are seen to be dark red, but 
in grave cases the characteristic brown, dry, furred tongue of typhus 
fever is present. 

The lips desquamate and bleed a good deal, especially in older 
children, who pick almost incessantly at them. The so-called sooty 
coating of the lips is the result, in this disease, of the blood drying 
upon their surface. The fetor of the mouth, which in adults is so fear- 
fully disgusting, is less intensely marked in children. 

The parotid gland occasionally swells up in typhous children, and 
is always to be regarded as a most dangerous symptom. It is 
not possible to say with any certainty whether all kinds of parotitis 
are of a metastatic nature, for the catarrh of the mouth may indeed be 
directly propagated to the Stenonian duct and even to the salivary 
gland itself. But the dangerous character of this complication and the 
fatal termination that ensues in most instances make it probable that, 
in the majority of cases the cause of the parotitis is an actual metas- 
tasis, and not a simple propagation of the catarrh. It invariabl}'- ter- 
minates in suppuration, and, if life continues sufficiently long, the gland 
undergoes purulent degeneration. In the cadaver a number of small 



484 DISEASES OF CHILDREN. 

abscesses, of the size of pins' heads, are always found associated Avith 
larger ones. 

The morbid phenomena are usually ushered in with vomiting ^ 
young children often vomit several times a day during the whole course 
of the disease, omog to which, when unattended by diarrhoea, it be- 
comes extremely difficult to diagnosticate the disease under considera- 
tion from acute hydrocephalus. This obstinate vomiting is due to a 
profuse gastric catarrh, as is shown by the fact that the patients not 
only throw ujj the little fluid nourishment they consume, but also con- 
siderable quantities of mucus, through which they become rapidly 
atrophied and usually succumb to the disease. The vomiting which 
accompanies perforative peritonitis in the adult is rarely seen in 
children, for the simple reason that the inducing cause, perforation of 
the intestines, scarcely ever occurs. 

The ahdominal pains and tenderness which accompany this disease 
in the adult are hardly ever complained of, and difficult to be elicited, 
in children under two years of age ; they occur only occasionally in 
older ones, and are not very severe. The importance of gurgling in 
the cmcal region, which w^as formerly described as a pathognomonic 
symptom of typhus fever, has deservedly fallen into disrepute, for it 
is just as frequently found in every intestinal catarrh. 

The tympanitis attending those cases in which the ulceration is 
limited is not very great, and consequently its effects, such as impeded 
respiration, from the pressure of the diaphragm upward, pulmonary 
stenosis, and cyanosis, occur only in milder degrees. 

The intestinal evacuations diifer in no respect from those in the 
adult. Diarrhoea is not usually present during the first few days of the 
disease, but it always comes on later, though laxatives may not have 
been used, and constipating drinks may have been given ; from twenty 
to thirty dejections taking place during the day. A collection of all 
the stools evacuated in the twenty-four hours, in children, is of course 
altogether out of the question, but it may approximatively be stated 
that, according to the weight and space, tyjjhous children discharge 
three or four times as much as healthy ones. The quantity dis- 
charged in the twenty-four hours does not always stand in relation to 
the number of evacuations ; some children discharge a larger quantity 
of typhous fcEces in two or three stools, than others do in ten or twelve, 
the number depending entirely upon the irritability of the rectum. 

If the stools are very thin, they wull be of a light-brown color, and 
when allowed to stand quietly will separate themselves into two lay- 
ers, an upper, clear, and fluid, and a lower, semisolid part. The latter 
consists of fine Avhite and yellow flakes. True, strong drastic purga- 
tives repeated several times in succession produce stools, which, as re- 



MIASMATIC DISEASES. 485 

gards tlie color and formation of the layers, cannot be distingnislied from 
those of typhus fever, but such drastic remedies are now scarcely ever 
employed even in the least rational methods of treatment. We there- 
fore have, in the formation of the layers, an important aid in the 
diagnosis of typhus fever. The absence of very profuse diarrhoea 
does not by any means prove the absence of typhus, for it is common 
to see children, after they have passed the second dentition, who, dur- 
ing the entire illness, are obstinately constipated, and in whom an 
evacuation has to be produced by clysters. The microscopic investi- 
gation of the yellowish flakes composing this lower layer reveals first 
of all: (1.) A totally formless granular mass, but little susceptible to 
reagents ; (2.) Intensely yellow-tinged scales, of pavement-epithelium 
(whole cylindrical epithelium cells are but very rarely seen) ; (3.) 
Brown, finely-granular corpuscles of various size and without mem- 
branes, as may be readily seen by cautiously compressing them ; (4.) 
Large brown, often double-contoured round or oval, and sometimes dis- 
tinctly rhomboid, refracting bodies ; (5.) Triple phosphates ; and (6.) 
Infusoria, the constant accompaniment of every putrefaction. These 
are objects which also exist in diarrhoeic stools, and consequently are not 
pathognomonic of typhus fever. Nor is chemistry able to demonstrate 
a peculiar typhous material. Typhous stools generate more sulpho- 
hydrogen gas than diarrhoeic, a fact which may be proven by paper 
moistened in a solution of sugar of lead, and that they contain a 
greater amount of ammonia can be shown by testing them with re- 
duced litmus-paper, which they turn intensely blue. 

Nothing can be gathered, to show any difi"erence between typhous 
and diarrhoeal stools, from the quantity of the salts, the various anal- 
yses of which I have had an opportunity of presenting more in detail 
in a former work. 

These profuse diarrhoeal evacuations generally last from eight to 
fourteen days ; then constipation sets in. Comparatively speaking, it 
is rare for diarrhoea to last longer than that period in children, as the 
intestinal complication in them is less intense than in adults. So 
long as the children are feverish, they discharge the contents of the 
bowels in bed, but it is necessary to discriminate between simply fre- 
quent involuntary discharges, the consequence of inattention, or the 
blunted state of their sensorium, and the constantly oozing away from 
them of liquid fteces, owing to the paralysis of the sphincters. The 
former condition is a common one, and denotes a veiy severe ty- 
phus, but its prognosis may be favorable. The latter, on the con- 
trary, is a symptom of the utmost exhaustion and profound depres- 
sion of the nervous system, and is to be regarded as an unfavorable 

sign. 

32 



486 DISEASES OF CHILDREN. 

Typhous intestinal hcemorrhage and intestinal perforations are 
exceedingly rare in children ; their s}TGnptoms and consequences differ 
in no respect from those occurring in adults, and it is assumed that 
they are suflBciently familiar to the reader. 

In some malignant epidemics, a croupous process of the large 
intestines becomes associated with the disease during the third or 
fourth week, when the children will discharge dysenteric stools, sink 
rapidly into a state of collapse, and perish comatose, or during a con- 
■mlsive attack. At the autopsy, an extensively-developed croupous 
membrane is found upon the mucous membrane of the large intes- 
tines, accompanied by ulcerations in various stages, such as have 
been more minutely described in dysentery. 

Tlie sjyleen is generally enlarged, but its change is demonstrated 
by physical examination with much more difl&culty than is usually 
supposed, this difficulty being subject to unavoidable and incalculable 
fluctuations. In a healthy child of one to two years old, a slight 
dulness over a space of barely one inch in length, and one-half an 
inch in breadth, may be detected on the left side, between the eighth 
and ninth ribs. A perpendicular line drawn from the middle of the 
axillary cavity to the great trochanter intersects this spot. The 
normal spleen lies with its long axis parallel to that of the body, the 
lower border projecting a little forward ; but, when it becomes en- 
larged, its position becomes more and more horizontal ; still the 
lower end always remains slightly deeper than the upper. In pro- 
gressive enlargement, the lower border gTOWS forward and doAvnward, 
reaching toward the cartilaginous border of the ribs, and pushes 
itself anteriorly along the abdominal wall, while the upper posterior 
end of the spleen develops posteriorly along the course of the ninth 
rib toward the spinous processes, so that, in percussing the back 
between the spleen and spinal column, only a narrow sonorous stripe 
is now found. The larger the spleen becomes, the more does it pass 
out of the horizontal into the perpendicular position. In typhus 
fever the spleen may become enlarged to three or four fold its normal 
size, and the hypertrophy is found to be disproportionately greater in 
its longitudinal diameter than transversely. 

The splenic tumor of tj^ohus is always easily movable, and with 
every deep inspiration is pushed do^vnward, a fact that may be more 
easily ascertained by percussion than by pressure with the finger over 
the border of the ril:>s. It is particularly remarkable how difficult it 
is to feel a hypertrophied t^^phus-spleen, which often projects over the 
borders of the ribs. Tliis is explicable by its extreme softness and 



MIASMATIC DISEASES. 487 

great mobility. The principal amount of swelling of the spleen takes 
place in the first and second week ; in the third week it begins to 
decrease, and on the fourth has become reduced to its normal size. 

The tympanites of the alimentary canal, which is naturally some- 
times variable, according to the predominance of the catarrh and 
the retardation of the peristaltic action, is a great obstacle to the ex- 
amination of the enlarged spleen. The increased amount of space 
occupied by the intestines is not effected at the expense of the 
abdominal walls alone, but at that of the rest of the abdominal viscera 
also. The liver turns its sharp border more and more upward, and 
presses the diaphragm further up, but the spleen is pushed upward 
and hacJcward, and invaginates itself in the distended intestines^ in 
which position even a very decidedly enlarged spleen cannot be de- 
tected by percussion. The diagnosis of typhus fever would therefore 
frequently be impossible, if the demonstration of the splenic tumor 
were to be regarded as essential. It does not, by any means, follow 
from this, that the percussion of the spleen is to be omitted as useless ; 
it should only be borne in mind that a greater dulness in the splenic 
region is not constant, and that consequently a well-marked typhus 
fever may exist without such dulness. 

Embolic inflammation of the spleen arises only in pygemia, and is 
rarely seen except in children in hospital. 

The morbid alterations of the respiratory organs are just as con- 
stant as those of the digestive organs. All typhous children have 
bronchitis and cough, but those under five or six years of age regu- 
larly swallow the mucus which is loosened by cough and thrown into 
the fauces. The more intense the disease, the more insignificant and 
less frequent is the cough ; not that the bronchitis is milder, but that 
the sensibility of the mucous membrane is so blunted that the ac- 
cumulated masses of mucus no longer excite the acts of coughing. 
On ausctdtatinsf the luno-s, laro-e and small sibilant rales are heard 
everywhere. The accumulated mucus ultimately produces an occlu- 
sion of the smaller bronchi, and the well-known hypostatic spleniza- 
tion then results. These are only to be found in the posterior and 
lowest parts of the lungs, diminishing the resonance upon percussion 
in these regions. But the well-declared dulness of a pneumonic lung 
is not found in these cases, and the detecting of the finer variations 
of the percussion-sound is rendered very difficult here, by the circum- 
stances that the splenization, in most instances, occurs in both lungs, 
and therefore a comparison of the percussion-sounds on both sides is 
impracticable. Sometimes distinct bronchial respiration is heard over 
the splenizated portions, but Avhether at first, or when the splenization 



^gg DISEASES OF CHILDREN. 

takes place, or at the end, when, in rarer instances, it -^ergoes reso- 
lution, can any pathognomonic crepitation, such as is heard in pneu 
nionia be discovered. As the splenization increases, the breathing 
becomes accelerated, the al^ nasi rise with every inspiration, a symp- 
tom upon which, in the difficulties attending the physical examination 
of the chest of restless children, too much attention cannot be be- 
stowed. Slight cyanosis at length supervenes, the cerebral symptoms 
become intensified, the frequency of the pulse augmented, and the 
children slowly succumb. Small splenizations seem to be capable of 
undergoing resolution, larger ones almost always destroy life The 
convalescence, when splenization has taken place, is always protracted, 
and the cough does not disappear entirely till after many months. 

Lohular pneumonia is frequently met with in the dissections o 
children who die of typhus, and may occur in the splenizated as well 
as in the sound parts. They are recognized by their firm, fixed exu- 
dation, and the granular appearance of the cut surfaces. ^^ e have no 
diao-nostic signs for this condition ; for the accelerated respiration, the 
movements of the aloi nasi, and the extraordinarily rapid P^^^^e are 
equally constant in a splenizarion, in a difaised typhous bronchitis 
without splenization, and in lobular pneumonia. Such circumscribed 
consolidations of the pulmonary tissues cannot be detected by aus- 
cultation and percussion. 

(Edema of the lungs is also frequently observed m the dissec- 
tions and seems to be the effects of prolonged imperfect respiration 
durino- the last hours of life. Pulmonary tuberculosis may develop 
itself "rapidly in children who inherit such a disposition. It does not 
usually appear till after recovery from the fever, but is much rarer 
after typhus than after measles, as a result of which it manife^sts itself 
in a great many children. Recurrence of fever, increased cough, 
and expectoration, allow its existence to be surmised, though the 
phvsical examination seldom positively confirms this suspicion in 
the beo-innino-. The bronchial glands are frequently found so much 
enlarged as to have aggravated the dyspnoea, but their h3Tertrophy 
cannot be diagnosticated. 

Abscesses of the larynx are said to have occurred, though i have 
not met with a simple laryngeal abscess in my dissections. In some 
there were present perichondritis and necrosis of the cartilages 
Usually the laryngeal affection first comes on in the third or fourth 
week of a severe typhus, and belongs to the secondary spiiptoms 
The patients suddenly become hoarse, then completely aphonic, and 
are attacked by a barking croupous cough and fever; the most vio- 
lent dyspnoea soon becomes superadded, and they die of frightful suf- 
focation. At the autopsy, more or less extensive necrosis of the 



MIASMATIC DISEASES. 489 

laryngeal cartilages is found ; the necrosed pieces of cartilage are 
bathed in sanguinolent serum, and the glottis is oedematous. Cases oi 
spontaneous recovery, with permanent hoarseness and even aphonia, 
are said to have occurred, but the most experienced physicians re- 
gard necrosis of the larynx as fatal. In adults with typhous laryngeal 
necrosis, laryngotomy is attended by tolerably favorable results. I 
have seen some individuals in whom it was performed with success, 
and would not hesitate for a moment to undertake the operation, 
should I again chance to have a child with necrosis of the larynx 
under treatment. 

Now, although, catarrhal laryngitis may also come on in typhus 
fever, as it may indeed in any other disease, and disappear sponta- 
neously, or, by the aid of counter-irritants, in a few days, still hoarse- 
ness in a typhous child must always excite the greatest anxiety, 
and it is advisable to be ready to perform tracheotomy, so that it 
may be instantly done when the dyspnoea becomes so serious as to 
endanger life. 

The skin of typhous children exhibits manifold alterations. A 
number of bright spots appear from time to time, between the fifth and 
tenth days after the invasion of the fever, upon the breast and abdo- 
men, but very seldom and sparsely on the rest of the body. These 
spots vary in size from a pin's head to that of a lentil, disappear on 
pressure, but instantly return, with uniform redness, so that it 
is impossible to decide whether the redness recurs from the centre to 
the periphery, or vice versa. Moseola typhosa^ taches lenticularis. 
Generally they are on a level with the skin, only exceptionally do 
they become elevated above it after the manner of morbilli ; they 
have no connection with the hair-foUicles, and sudoriparous glands, 
and are not perceptible to the patients themselves. 

It is not always very easy to distinguish between roseola typhosa 
and flea-bites. But flea-bites are brought into the disease, fade more 
and more daily, and are not replaced by new ones, because fleas for- 
sake all febrile patients, while the exanthema of typhus fever does not 
appear for some days after the child has been seriously sick. 

The eruption of the typhous exanthema does not take place at once, 
the course is by no means typical ; some spots remain for a longer, 
others for a shorter period ; while some have already faded, others ap^ 
pear again on new places, and herein we have important distinctions 
from the acute exanthemata. Typhous roseola always lasts several 
days ; when an exacerbation of the fever takes place, it becomes 
darker ; when a remission ensues, paler, and finally fades to the nor- 
mal color of the skin, having passed through a brownish or yellowish- 
red tint. Almost all seriously sick typhous children present these 



490 DISEASES OF CHILDRExV 

roseola spots ; in milder forms of typhus abdominalis they are not 
seen. The number of spots is of less consequence in reference to the 
prognosis than the color and duration of the eruption ; the bluer the 
spots, the more .dangerous is the condition. 

The persjyiratlons are seldom critical in tyj^hus fever. Some chil- 
di-en perspire from the very beginning, though the typhous symptoms 
are becoming more and more aggravated ; others pass into a perfect 
convalescence with a barely moist skin. 

In most typhous children tniliaries appear in gi-eat numbers. 
They have no critical and still less any unfavorable signification, and 
it is wholly inexplicable how such a dreadful fear of these harmless 
little sudamina has arisen among the laity of all classes. The 
manner of their origin is extremely simple. As a result of the ces- 
sation of the perspiration at the commencement of the fever, the 
epithelial cells lining the excretory ducts of the sudoriparous glands 
become dry, are cast off, but not washed away, forming a dam, 
which the perspiration, that has been arrested for some time, but 
which now, suddenly reestablished and profusely secreted, is unable 
to break through, thus causing an elevation of the occluded orifice, 
and the similarly desiccated layer of epidermis surrounding it, to the 
extent of a pin's head in circumference. After two, or, at the longest, 
three days, these epidermial caps burst, and the perspiration oozes 
out uninterruptedly through the once more pervious and cleansed 
jDassage. Microchemical investigations give evidence that the con- 
tents of the miliaries are not a serous exudation of the cutis, but pure 
sweat, and, by placing the cap of a mihary vesicle under the micro- 
scope, it wiR be easy for one to convince himself that the mouth of a 
sweat-gland exists in its centre, which is recogTiized by the concen- 
tric layer of the epidermic cells, and is never seen open, but always 
closed by larger and smaller granules. 

These miliary vesicles are found largest and in greatest abundance 
upon places where cutaneous irritants, sinapisms, or ung. cinereum,* 
have been applied. There they often attain the size of a lentil ; the 
skin, after they burst, peels off in large patches, almost as in scarla- 
tina, and the new cuticle for a long time has a brighter color than that 
by which it is surrounded. This phenomenon is also easily explained, 
for, by the use of unguents, the ducts of the sweat-glands are still 
more completely closed up, and by rubefacients a congestion of the 
cutis is produced, in which naturally the glandular canals must become 
implicated. The miliaries can be regarded as critical only to the extent 
that they show that the long-interrupted secretion of the sweat has 
again become established, a truly desirable and encouraging sjonptom. 
* [Oxyd of mercury ointment.] 



MIASMATIC DISEASES. 491 

Furuncles^ abscesses of the cellular tissue, and bed-sores, have to- 
tally different significations. During convalescence, an extremely 
painful furunculosis, principally upon the head and nape of the neck, 
sometimes becomes superadded, causing the child much suffering for 
many weeks, greatly retarding its complete recovery. The numerous 
subcutaneous abscesses, which appear as sequelae of the disease, pro- 
duce a like result. 

Cleanly-kept children are attacked by bed-sores at a much later 
period than adults, and the sores are less extensive. The epider- 
mis usually sloughs off from several small places on the back, over 
the sacrum, nates, or trochanters, and leaves a superficial ulcer, 
which, as a rule, heals by the application of some simple astrin- 
gent ointment. Extensive cutaneous destruction of the skin over 
the sacrum, where it becomes blue and gangrenous suddenly, and 
sloughs off in a couple of days, may occur, perhaps, in badly-ven- 
tilated hospitals ; however, I have never met with them in private 
practice. 

On the lower extremities petechice are sometimes seen in typhous 
children, who lie in very damp, miserable rooms, and are affected with 
scurvy. They differ in no respect from those observed in common 
scorbutus. 

Facial erysipelas is sometimes seen in the adult as a local mani- 
festation of a pyEemic inflammation of the superior maxillary cavities, 
but I have never yet observed it in children. 

The head and nervous symptoms are not so marked in typhous 
children as would be supposed from their general irritability. Most 
of the milder cases run their course, attended only by mental apathy 
and general depression of the spirits. In severer cases, delirium of 
various degrees, at first by night, later also in the daytime, comes on, 
followed by many hours of profound coma. The division of febris 
nervosa into a versatilis and stupida can be entertained no more in 
children than in adults, and only when one or the other condition has 
been continuous for several days may the therapeutic indication pos- 
sibly become changed. Sometimes the delirium lasts only one, at 
other times several days, generally, however, two to three weeks, 
when it ceases, not at once, but gradually, and leaves behind great 
irritability, and weakness of memory, which in some children may re- 
main permanent for life. Sometimes the sensorium clears up after a 
profuse epistaxis, after an intestinal haemorrhage, or after a profuse 
diarrhoea. 

The muscular weakness of typhous children is exceedingly great ; 
most of them lie perfectly quiet upon the back, and are not even able 
to sit up. The usual tympanitis is, in part, also attributable to a 



492 DISEASES OF CHILDREN. 

paralysis of the muscular coat of the intestines ; the hardness of hear- 
ing may be explained more simply by the fact of a mechanical inter- 
ruption in the transmission of the sound, which ensues more as a result 
of catarrh of the Eustachian tubes, than by the toxic eflfect of typhous 
blood. The muscular weakness peculiar to typhus fever is to be dis- 
tinguished from a partial paralysis of the loAver extremities, which is 
protracted disproportionately into the convalescence, but finally passes 
off spontaneously, no matter whether the much-lauded electricity has 
been resorted to or not. 

In regard to the urine of typhous children, and the uropoetic sys- 
tem, and genitals, but Httle can be reported, on account of the impos- 
sibility of properly collecting the urine, and the subordinate significa- 
tion of the infantile genitals in particular, I once saw diphtheritis of 
the vagina, and resulting gangrene of the labise majora and minora 
in a girl two years old. She belonged to a wealthy family, and was 
very well nursed ; but, notwithstanding the most energetic use of 
escharotics and a general tonic and stimulating treatment, death 
ensued in a very few days. 

Metastases, in the sense of the older school, do not occur in ty- 
phus fever. In these were included phlebitis, fvirunculosis, cuta- 
neous abscesses, emboHc inflammations of the parenchymatous organs, 
and gangrene. But since the time that the misplacement of the co- 
agulffi and the causes of the formation of emboli have, mainly 
through the labors of Virchoxo, been more accurately ascertained, 
and since the time that the py£emic process and its occurrence in the 
various cavities and organs have been more thoroughly investigated, 
all those theories have completely changed. Although all the cir- 
cumstances are not yet fully explained, still this much has been eluci- 
dated : that they depend in greater part upon mechanical disturbance 
of the circulation, and hence we are not compelled to have recourse to 
the mysterious metastases. 

Actual relapses but very rarely occur in children ; though scarcely 
any typhous child progresses steadily toward a complete recovery 
without a longer or shorter interruption, because, urged by a keen 
appetite, they wiU eat indiscreetly if food is furnished them, and, 
when unable to get it, will swallow wholly undigestible substances, 
such as paper, etc. In children with an hereditary disposition, tuber- 
culosis is the most frequent sequel to which they succumb after 
many months ; in scrofulous persons, profusely-secreting exanthema- 
ta, eczema, impetigo, and malignant otorrhoea, ensue, along with 
which the tympanum generally becomes perforated, and the bones of 
the ear are discharged. Thejinale of this painful, tedious, and annoy- 
ing result is total deafness. Noma is one of the exclusive complica- 



MIASMATIC DISEASES. 493 

tions of typhus fever of children which occasionally supervenes during 
convalescence, and principally attacks them in badly-ventilated and 
damp localities. We have already spoken of this affection at p. 97. 

Therapeutics. — It is much easier to harm a typhous child with 
medicine than to do it good. Much injury tnay he done by the ad- 
ministration of emetics or drastic cathartics^ although the premoni- 
tory symptoms of tj^phus fever may often seem to indicate such 
medication. I frankly confess that I have occasionally been led into 
this error, and have administered to an intensely congested and con- 
stipated child, presenting a white furred tongue, an emetic consist- 
ing of ipecacuanha 3j, tart, stibiat. gr. j, and I have uniformly 
observed, as an apparent result, that the fever which followed was of 
the highest grade. That this should have been a mere coincidence, is, 
I think, altogether out of the question, and hence I deem it necessary 
to speak decidedly against the use of tartar emetic in aJl cases of chil- 
dren presenting the least symptoms of typhus fever. 

Those prophylactic measures minutely described in text-books 
(such as ventilation, proper nourishment, occupation, etc.) certainly 
deserve the utmost encouragement, but they are, in most instances, 
more easily prescribed than secured. One has quite enough to con- 
tend with in having the typhous child transferred from the small back 
room, occupied by the whole family, into the so-called parlor, a com- 
paratively vacant room, containing only a few articles of luxury. In 
more commodious residences, two communicating rooms should be 
retained and appropriated to the use of the sick child, for by this 
means only can a thorough ventilation be obtained. Admitting the 
question of infection to be extremely problematical, it is nevertheless 
advisable, if only to maintain the necessary quietude, that no children, 
and, at the most, only two adult persons, be allowed in the room with 
the sick child. The temperature of the room should never rise above 
65° F., the covering should always be light, the mattresses tolerably 
hard, made of . sea-weeds, straw, or horse-hair. If the typhous 
sjTnptoms are already fully developed, it is advisable to have the 
hair cut short, by which a proper amount of cooling of the con- 
gested head is secured. Cold-water applications to it, which the 
laity generally carry out by dipping a thin piece of cotton cloth in 
cold water and spreading it out between two dry ones, and then 
tying it over the forehead, cools but for a minute at the most. 
It very soon rises to the temperatvu'e of the skin, and then it heats 
rather than cools, as one may easily convince himself by seeing and 
feeling children so treated. I do not believe that cold compresses 
laid upon the forehead give much relief, for, as they become Avarm 
very soon, they require to be often changed, and this act annoys the 



494 DISEASES OF CHILDREN. 

child, and thus do more harm than good. If the child be too young 
to listen to reason, or delirious in consequence of the disease, this 
manner of applying cold will not answer at all, and we will have to 
limit ourselves to douching the closely-sheared head every hour with 
cold water, holding it over a basin, w^hile the body is protected by a 
cloth wrapped around the neck. 

The treatment of typhus fever for the first few days must be 
purely expectant, for the reason that the diagnosis cannot be 
certainly made out, and, as has already been stated, all energetic 
remedies, among which may be included leeches to the temples, for 
the purpose of combating congestion, are injurious. Hence, we 
must limit ourselves, when constipation exists, to the administration 
of some mild acidulous drinks, composed of any agreeable vege- 
table acid, or to a few drops of acid Halleri, while, if diarrhoea has 
abeady become superadded, the mucilaginous agents are more appro- 
priate. In this connection, I can say of calomel, that when given 
several times in medium doses, say two to four grains, it procures 
a certain but gentle evacuation of the bowels, without being followed 
by such profuse diarrhoea as tart, stibiat. or the other drastic remedies. 
An abortive effect from medication is, of course, altogether out of the 
question. This expectant treatment having been pursued for from 
ten to fourteen days, and neither improvement nor aggravation of 
the disease having become manifest, a diet of more nutritious aliment 
should be commenced. 

The diet of t^^phous children depends upon their age and former 
manner of living. Many children, w^ho, while in health, mainly lived 
upon milk food, will not taste bouillon and demulcent soups at all, 
which, in adults, are considered the most appropriate nutriments; 
and there is therefore no other alternative than to allow them also 
during the fever small quantities of milk, or coffee with milk, several 
times a day, although it cannot be denied that the diarrhoea is thereby 
aggravated, and that large coagulae of undigested milk may some- 
times be found in the stools. We must endeavor, by the aid of thick 
mucilaginous drinks, a thick decoction of salep-water, gum-water, rice- 
water, etc., to counteract the inevitable irritation from the lactic acid 
of the milk consumed. Children seriously ill of typhus require noth- 
ing else than cold water, and for days will refuse all other drinks, 
even milk and soups, and they do not become more emaciated than 
others who partake of nourishment several times a day. It is there- 
fore very questionable whether the food administered to typhous 
children is generally assimilated. When collapse becomes very 
threatening, or in commencing splenization, and the pulse begins to 
sink, a tonic and stimulating diet is urgently called for. 



MIASMATIC DISEASES. 495 

In coffee we have a convenient and easily-procurable stimulating 
remedy, which, on account of its agreeable taste, is preferred to all 
other excitants, such as camphor, musk, castoreum, ammoniacum, etc. 
With one cupful of strong, sweetened coffee, containing but little 
milk, the powers of the system will often revive, and the circulation 
receive new impetus. In addition, beef -broth with yolk of eggs must 
be tried, and may also be administered per rectum. Camphor is very 
difficult to administer to children, and usually causes vomiting. Musk 
also behaves in the same way, besides communicating its disagree- 
able odor to the whole house. Cold affusions usually recall con- 
sciou.sness, invigorate the respiratory functions, and induce perspira- 
tion. If there be several unconscious dischai-ges from the bowels 
daily, tepid baths of 88° F, should be employed, in which the childi-en 
may be kept for from five to ten minutes, or sufficiently long to thor- 
oughly clean them. Miliary eruptions, roseola typhosa, and bron- 
chitis, are not to be regarded as contraindicating these baths. Now, 
if by the third or fourth week a lively appetite has set in, the utmost 
precaution will have to be exercised. Mucilaginous and beef soups, 
milk, coffee, and milk-broth, may be continued till complete consti- 
pation, freedom from fever, and a clean tongue, take place ; then 
well-prepared chicken or veal may be tried. Fat nutriments and 
green vegetables should be avoided for a long time ; indeed, it is 
best to defer giving them till the children are able to go about. With 
this simple, expectant treatment, the majority of the cases will ter- 
minate favorably. Should any symptoms become especially threat- 
ening, they will, of course, have to be specially attended to. 

The best remedy for the fever and congestion of the head is cold. 
The means by which this is accomplished are : cool temperature of 
the room, from 58 to 64° F., light coverings, hair cut short, pillow of 
horse-hair encased in soft deerskin, hourly cold douching of the head, 
cold affusions of the whole body, once or at most twice daily, and a 
bladder filled with ice to the head — this, however, is applicable only 
to large children when not delirious. I have never yet seen any benefit 
from sinapisms applied to the nape of the neck, the calves of the legs, 
or the feet. The redness and great sensitiveness of the skin, which 
lasts for several days, and which invariably result from those sina- 
pisms, always excite sick children and make them still more restless. 
Blisters should never be applied to a typhous child ; they heal very 
slowly at best, frequently become covered with a diphtheritic exuda- 
tion, and even gangrenous. The antipyretic action of chinin, salicylic 
acid, and of eucalyptus, which are so generally recommended in this 
disease, is by no means always permanent or marked. The same is 
true of the cold pack. Where the fever is high, it will be necessary 
to administer these remedies in large doses frequently repeated. 



496 DISEASES OF CHILDREN. 

[Quite recently antipyrine has been brought to the notice of the 
profession by Fllhene, of Erlangen. Biermer, of Breslau, and Dra- 
per^ of New York, also used it, and found that it possessed the 
remarkable property of reducing the temperature without causing 
any ill effects. In some cases, however, the redaction of tempera- 
ture was attended by vomiting and marked perspiration. These 
investigators found that when antipyrene was administered to pa- 
tients suffering from typhoid fever, pneumonia, or the like, in doses 
of 3 ss. every hour until 3 iss. to 3 ij. was consumed, the tempera- 
ture fell from 104° to 100° F., or even to normal. The apyretic 
period lasts for from eight to nine hours, then the temperature 
begins to rise again, without the chill which occurs after the use of 
kairine, usually attaining the maximum in twelve hours {Draper). 
The dose of this remedy for children from two to five years of age 
is grs. iij every hour ; to older ones, grs. v to grs. viij, suspended in 
syrup of tolu. The remedy is equally useful in pneumonia, and all 
other febrile affections attended by a high temperature.] 

The best remedy for the excitement, sleeplessness, and delirium, 
in this disease, is laudanum. One drop less than the number of years 
of the age of the child should be given : thus, to a child three years 
of age, two drops, to one four years, three drops, etc. ; and this may 
be relocated twice or thrice daily. I have never yet seen any of the 
bad effects attributed to opium, such as collapse, profound sopor, 
depression of the pulse, cyanosis, etc., from this practice, but have 
always noticed that children obtained several hours' rest, refreshing 
alike to themselves and their attendants, without any untoward 
change in the course of the fever. 

Against the great exhaustion, feeble pulse, cool, bluish skin, in- 
dicating supervening splenization of the posterior parts of the lungs, 
a tonic and stimulating treatment will have to be employed, in which 
I give to coffee the most prominent position ; wine, which, in adults, 
justly plays such an important r6le, must be used very carefully in 
children, because alcoholic drinks affect some infantile brains very 
unfavorably, inducing furious delirium. Internally, it is best to give 
a few drops of valerian, camphor, or acetic ether. Nothing praise- 
worthy can be said of the tonic effects of quinine in these cases ; dry 
cups, applied several times a day to the anterior and lateral parts of 
the thorax, are not only theoretically rational, but practically exer- 
cise a tolerably favorable influence upon the splenization. 

Moderate epistaxis always brings about relief and rest. The 
nurses should be instructed to allow the blood to flow into an empty 
vessel, one that does not contain any water, because otherwise the 
amount of blood lost is usually estimated too high, and we might 
hasten to arrest the hseraorrhage, which usually ends quite soon 



MIASMATIC DISEASES. 497 

enough. The tampon is indicated, as a rule, only when the amount 
of blood lost exceeds two or three ounces. It is generally sufficient 
to push a small piece of ice into the nasal cavity and then plug it 
with some charpie. It will scarcely ever be necessary to tampon 
the posterior nares by the aid of JBellocqu&'s tube, an operation 
which annoys and frightens the child very much. To determine 
that the haemorrhage has really been checked, the child, after the 
tampon has been applied, should be laid upon the face, or the head 
should be held forward a little, as, otherwise, the bleeding may con- 
tinue, and the blood may flow backward and be swallowed. 

Typhous diarrhcea cannot be completely arrested by any rem- 
edy : opium controls it a little ; astringents and mucilaginous 
agents usually have no effect upon it. In general, however, the 
diarrhceal discharges in children are seldom as profuse and persist- 
ent as in adults. 

Constipation is sometimes a disagreeable symptom in the course 
of typhus fever, occurring at certain times almost epidemically. It 
should never be relieved by purgatives, but only with clysters. If 
the latter have proved ineffectual, calomel is the only remedy which 
may be given internally, for the aqueous extract of rhubarb or cas- 
tor-oil is difficult to administer to children. In conclusion, I feel it 
a duty to admonish against the use of all debilitating measures, to 
spare the strength of the child as much as possible under all cir- 
cumstances, and to carefully avoid the practice of active antiphlo- 
gistic measures. 

(5.) [Cerebeo- SPINAL Meningitis, Epidemic Cerebro-spinal 
Meningitis, Cerebro-spinal Fever, Congestive or Petechial Fever, 
Malignant Purpuric Fever, and Sycopal Typhus Fever, by one or 
all of these terms is understood a disease affecting the meninges of 
the brain and spinal cord, accompanied by fever and an eruption of 
spots upon the face and body. The sporadic form of the disease 
runs its course in a mild manner, but the epidemic is attended by 
high fever and constitutional phenomena. It is now admitted by 
most authorities to be infectious, and may be regarded as a spe- 
cific disease, with localization upon the meninges of the brain and 
cord, analogous to diphtheria with its manifestations upon the ton- 
sils and throat. Although undoubtedly long ago known to medical 
writers, yet the disease seems to have been only fully recognized 
and described as a distinct disease in the early part of this century. 
None of the glandular organs nor the mucous membranes are af- 
fected in this disease. The hypersemiaes that are found after death 
present no constant features, and have been observed in various 
maladies. The eruption has nothing in common with the exanthe- 
mata of typhus. Nor does the progress of the fever, with its at- 



498 DISEASES OF CHILDREN. 

tendant cerebral phenomena and the absence of a typical course, 
show any connection between it and typhus fever. 

Etiology. — The early writers on this disease supposed that, owing 
to its marked intermittent character and the irregularity of its 
course, it was analogous to intermittent fever and caused by malarial 
emanations. But it has since been found that it by no means always 
occurs in malarial districts ; being often met with in dry, sandy 
regions and great altitudes, and is not particularly malignant when 
it attacks persons living in malarial districts. Moreover, the ab- 
sence of splenic hypertrophy and the inefficiency of quinine in the 
treatment of the disease under consideration prove conclusively that 
the theory of its being of malarial origin is untenable. 

It attacks preferably children under twelve years of age. In 
the epidemic that prevailed in Franconia, according to Professor 
Jllrsch* the vast majority of its victims were children under nine 
years of age. Of the 975 cases that occurred during the epidemic 
which prevailed in this city during the year 1872, 771, or nearly 80 
per cent., were in children under fifteen years of age ; and of these, 
again, 665, or more than 68 per cent., were in children under ten 
years. In the correctional institutions of Belfast and Dublin only 
boys under twelve years of age were attacked, girls and adults es- 
caping altogether. In the epidemics mentioned above, the sex, also, 
seems to play an important part : more males than females suffered 
from cerebro-spinal fever, but that may be due to the difference 
in the occupation of the sexes. Cold and rainy weather, that pre- 
vails during the winter and spring months, favors its development. 
Various other causes are mentioned, such as bad sanitary surround- 
ings, poor and badly-ventilated rooms, improper and insufficient 
food, fatiguing and exhausting marches, and the confining of sol- 
diers in badly-constructed barracks. Mental excitement, fear, and 
anxiety, are also mentioned as being predisposing causes. In a case 
that came under my observation, a precocious girl twelve years old, 
the attack seemed to have been brought on by too close application 
to her studies, coupled with great anxiety concerning an approach- 
ing examination. Dr. Smith, I find, reports an almost analogous 
case. But these predisposing and exciting causes would not be 
sufficient to produce the disease " without the presence of some 
actual root or germ, the materies morbi," f that is called into action 
by the surrounding influences favoring its development ; otherwise, 
nurslings would escape it entirely. Its true nature has not yet 
been ascertained. As has been already stated, it is undoubtedly in- 
fectious ; some even go so far as to claim that it is contagious, but 
it certainly " is not contagious in the sense that sraall-pox is." 

* Ziemssen's Cjclopcedia, vol. ii. f Bartholow's Practice of Medicine. 



MIASMATIC DISEASES. 499 

Pathological Anatomy. — The post-mortem examination reveals 
at the first glance a general inflammation with its attendant phe- 
nomena throughout the cerebro-spinal cavities. The meninges of the 
brain and cord are inflamed, the vessels injected ; here and there 
ecchymotic spots are seen. The true products of inflammation — 
exudation of lymph and effusion of serum — are found in the ven- 
tricles of the brain, between the meninges of the brain and spinal 
cord. The sinuses of the dura mater are tilled with coagulated 
blood ; where the disease has run a very violent course, the patches 
of lymph will be found to be quite thick, and, in some instances, even 
pus was observed. At first the exudation is clear, but soon it be- 
comes turbid and opaque, and finally yellowish and purulent. Ac- 
cording to JEhers, the purulent exudations of the meninges contain 
micrococci, and Gaudier and others claim to have found micrococci 
in great abundance in the blood and urine of a patient suffering 
from cerebro-spinal meningitis ; hence many writers on the disease 
are disposed to regard it as being due to a micro-organism in the 
blood. 

In the brain-substance and spinal cord numerous minute ex- 
travasations are seen, of the size of a pin's head to that of a lentil, 
attended by interstitial exudation. In extreme cases the brain- 
substance is (Edematous, softened, and, where the effusion has been 
extensive, the cerebral convolutions are flattened. The exudation 
is found in greatest abundance along the large vessels, in the fissure 
of Sylvius, optic chiasm, and pons Varolii. Generally, all the menin- 
ges of the cord show analogous morbid alterations to those of the 
brain, namely, the dura mater is hyperaemic and covered with exuda- 
tion, the arachnoid membrane is cloudy and opaque, due to infiltra- 
tion with pus-cells, but the pia mater is more or less thickened with 
exudative deposit. Even the roots of the nerves are covered with 
a layer of pus or gelatinous exudation, if the patient has lived long 
enough. As stated above, Ehers and Gaudier consider these purulent 
exudations to be foci of micrococci, while others regard them only 
as wandering leucocytes, in proof of which they point to the fact that 
they are found most abundantly in the course of the vessels. When 
the disease runs a violent course, and death ensues early, the post- 
mortem appearances may not be suflicient to account for the fatal 
termination. The meninges may be only h)'^per8emic, with a slight 
layer of lymph on the cerebral surface, or only in a few places, but 
some of these morbid lesions will always be found in this disease. 
The other internal organs do not show any pathognomonic lesions, 
and are often found similarly affected in other diseases. The heart 
is soft and flabby, the liver in a state of fatty degeneration, and, 
where the disease has lasted for some time, it may become compli- 



500 DISEASES OF CHILDREN. 

cated with nephritis. The agminated and solitary glands of the 
intestinal canal are congested and swollen. The blood is often 
found to have undergone marked changes. It is darker than nor- 
mal, rapidly undergoes decomposition, and contains a larger num- 
ber of white corpuscles and a diminution of the red ; it also con- 
tains less fibrine. The lungs may present the appearances of various 
grades of inflammation, or only of simple bronchitis or hypostatic 
congestion. According to Weber, all fatal cases are complicated 
with acute inflammation of the resjairatory organs. 

Symptoms. — The disease is ushered in under so many difiCerent 
forms and diversity of phenomena that writers are disposed to clas- 
sify it under many varieties, according to the individual symptoms 
being most distinct and pronounced in severity. But the individual 
symptoms are often misleading, the most violent subsiding in a few 
days and the case terminating favorably, while a case that commenced 
very mildly and did not present any alarming symptoms may, in its 
course, become comjslicated with some other disease and rapidly 
terminate in death. It is generally ushered in by a chill and vom- 
iting, followed by loss of appetite, pain in the limbs, back, and nape 
of the neck. Very often a violent attack of convulsions, succeeded 
by headache, coma, delirium, strabismus, dilated pupils, arching of 
the body backward, rapid pulse, fever, high temperature of the skin, 
are the initial symptoms. The headache is generally confined to the 
forehead and temples, and at every attempt the patient makes to rise 
or sit up the pains in the head become more intense ; the vertigo and 
nausea are particularly annoying to the patient. Most children 
refuse to raise their heads, though consciousness may not be abol- 
ished, for fear of falling. In some of the cases the headache and 
malaise precede the outburst of the disease for three days or more, 
and, in a mild case, it may be a question whether the malady will 
develop into a continued fever — typhus, or typhoid, or spotted fever ; 
but the high temperature, the muscular rigidity, retraction of the 
head, convulsions, and the character of the eruption, will decide the 
diagnosis. In the majority of the cases the mind soon becomes 
more or less affected. In the milder forms there seems to be only a 
slight dulness of comprehension, and the patient must be addressed 
in a loud voice in order to comprehend what is said to him ; in other 
cases, again, there is actual stupor, with delirium. There is no direct 
relation between the psychical phenomena and the termination of 
the disease ; still, as a rule, if the mind remains clear or is slightly 
cloudy, the chances of recovery are good. Vomiting is an almost 
constant and early symptom of the disease : at first the child vomits 
the last meal, and after that bilious matter or mucus ; the vomiting 



MIASMATIC DISEASES. 5OI 

is easily induced. The fever also conies on very early in tlie disease 
and is persistent, there being no daily remissions and exacerbations 
of the temperature. The thermometer may show a high grade of 
the fever, 105° or even 107° Fahr., from the very beginning of the 
attack, or, having marked but a moderate grade for several days in 
succession, it then suddenly attains to a high degree, on the sudden 
accession of some complication or extension of the inflammatory 
process within the cerebro-spiual spaces. A high fever is generally 
ominous of a fatal result. The pulse is irregular, now accelerated 
and then again retarded, but generally does not rise much above 
one hundred beats per minute, save toward the fatal end, when it 
may beat so rapidly as to be uncountable. In its irregularity the 
pulse resembles much in character that observed in simple menin- 
gitis. All the special senses are more or less involved. There is 
hardness of hearing, even in the cases where the stupor is not very 
profound ; also intolerance of light; the skin is exceedingly sensitive ; 
the senses of smell and taste are blunted. The muscles of the face 
twitch ; those of the extremities, especially of the upper, may be 
repeatedly convulsed or are rigidly contracted ; those of the neck and 
back are tense, arching the body, giving rise to opisthotonos ; the 
sphincters may become relaxed, especially toward the end of the 
disease, the patient voiding his urine and fceces involuntarily. The 
appetite is abolished; sordes form on the teeth, gums, and lips. Not 
unfrequently haemorrhages occur from various portions of the mu- 
cous membrane, the nose, mouth, or bowels. The respii'ation is 
irregular, now rapid and short, then again slow and deep. As the 
disease progresses and the exudation in the meninges increases, the 
breathing assumes the peculiar sighing character which has been 
designated the Cheyne-Stokes form. When the disease is ushered 
in with violent phenomena, such as convulsions, stupor or coma, hot 
skin, high temperature, and accelerated pulse, it will be a question 
whether the patient suffers from cerebro-spinal meningitis or scarlet 
fever, especially when both diseases prevail in an epidemic form 
simultaneously ; but a careful examination of the throat of the pa- 
tient and the general diffused exanthemata peculiar to scarlatina will 
prevent the physician from going astray. During the prevalence of 
an epidemic, different cases are apt to be differently affected. While 
in some patients all the characteristic symptoms ai"e developed to 
an extreme degree — coma, stupor, or at least somnolence, muttering, 
delirium, convulsions, retraction of the head, high temperature, and 
fever, with the peculiar ecchymotic spots — others present only slight 
twitching of the muscles of the face, headache, irregularity of the 
pulse, drowsiness, and vomiting or slight nausea, the temperature of 
33 



502 DISEASES OF CniLDREN. 

tlie skin remaining under 104° Falir. In these cases there is dan- 
ger of mistaking the disease for typhoid fever. The eruption of 
cerebro-spinal meningitis is peculiar and unlike any eruption met 
with in any other disease. The petechias of cerebro-spinal fever 
vary in size and color : some are small and bright red, others lai-ge 
and livid ; the latter indicate a disorganized condition of the blood 
and forebode extreme danger ; hence the name of spotted fever. In 
addition to these petechia;, which are caused by extravasations of 
blood into the subcutaneous cellular tissue, there are also generally 
present numerous herpetic eruptions and sudamina ; the former will 
be found well marked, especially upon the face and chest. These 
various eruptions and petechiae have been seen in the different epi- 
demics that prevailed from time to time. There is a tendency to 
haemorrhages from the mucous membrane of the nose, mouth, etc., 
especially in those cases where the petechise are so severe as to con- 
stitute extravasations of blood and ecchymosis in the subcutaneous 
tissue. The tongue is dry, there is marked thirst, and the quantity 
of the urine excreted is considerably diminished. The latter con- 
tains albumen, and is of a high specific gravity. Nephritis and 
broncho-pneumonia sometimes supervene and lead to a fatal result. 
Course and Termination. — It will scarcely be necessary to quote 
here any statistics to prove the dangerous character of the disease. 
The importance of the organs involved, the severity with which 
many of the victims are attacked, the intensity of the fever, and the 
character of the morbid lesions, are sufficient to account for the 
great mortality of the disease. More than half of the children un- 
der five years of age attacked by spotted fever die, especially when 
the temperature of the skin is high, the stupor profound and persist- 
ent, the convulsions or contractions of the muscles of the back and 
neck unyielding. As a rule, these cases terminate fatally very early 
in the disease. In the so-called fulminant form, the child is stricken 
down suddenly with such vehemence that no time is allowed for 
many of the symptoms to develop themselves, collapse taking place 
a few hours after the seizure. Here the most marked phenomena 
are the eruption, which consists of large ecchymotic spots, like pur- 
pura hsemorrhagica, accompanied by lividity of the skin, hemor- 
rhages from various parts of the body, coma, great prostration, in- 
voluntary evacuations of the bowels and bladder, death ensuing in 
a few hours, or, at the longest, days after the attack. In these pa- 
tients the symptoms set in early and continue with unabated fury 
to the end, prostration also being great from the very commence- 
ment. I am not aware of a single well-marked case being on record 
having recovered from cerebro-spinal fever belonging to this cate- 



MIASMATIC DISEASES. 503 

gory. Between this and the mild form, where the fever is moder- 
ate, the headaches slight, the somnolence transient, the convulsions, 
and the rigidity of the muscles of the back and of the neck only 
temporary, with consciousness returning, there are, of course, vari- 
ous grades and variations. Sometimes cases are met with in which 
the symptoms were ushered in with great violence, and, having 
lasted for several days, subside to such a degree as to lead one to 
expect a speedy recovery, but soon again become as violent as 
before. These, however, are rare instances, for most of them per- 
ish from some intercurrent complication ; those surviving remain 
maimed or ci-ippled for life, some one or more of the important 
organs or functions, such as sight or hearing, being impaired. One 
little fellow, who a year ago suffered from cerebro-spinal meningitis 
moderately severe in degree, still has frequent attacks of headaches 
and vertigo, which can be ascribed to no other cause, and can only 
be regarded as sequelae of that disease. 

The disease is liable to be mistaken for simple meningitis, scar- 
let fever, and typhus fever, and even pneumonia running an irregu- 
lar course. But the suddenness of the onset, the increasing high 
fever, the rigidity of the muscles of the nape of the neck and back, 
the extreme hypersesthesia, and the characteristic cerebral phenom- 
ena, the prevalence of an epidemic, and the distinctive eruption, will 
be sufficient guides to the formation of a differential diagnosis. 

Treatment. — It being now generally admitted that cerebro-spinal 
meningitis is an infectious disease, and since some of the causes that 
foster it are undoubtedly removable or avoidable, such as over- 
crowding of inmates in schools, orphan asylums, and correctional in- 
stitutions, faulty ventilation, uncleanliness, bad food, fatiguing du- 
ties, etc., the prophylaxis of the disease must, therefore, be of prime 
importance. Attention should be given to the sanitary condition of 
the localities surrounding the dwellings in which the disease has ap- 
peared, and also those that have been spared. During the prevalence 
of an epidemic, parents and guardians should be cautioned against 
being too strict with their children in their studies, and care should 
also be taken that they have proper food and clothing ; their rooms 
should be well ventilated ; they should not be exposed to cold and 
wet weather ; all harassing and vexatious matters should be scrupu- 
lously avoided ; in short, the best hygienic measures that are calcu- 
lated to arrest the spread of the disease should be enforced, both in 
public and private houses. If the disease has broken out in insti- 
tutions containing many children, such as schools, orphan asylums, 
or the like, the inmates should at once be removed from the insti- 
tution, and the building and grounds thoroughly overhauled and 
purified. 



50i DISEASES OF CHILDREN. 

As regards the medical treatment, considerable diversity of 
opinion still prevails concerning the remedies which promise the 
best results. Many physicians still recommend topical abstraction 
of blood by the application of leeches behind the ears or to the 
temples. But if we bear in mind the etiology of the disease, 
which is now generally accepted, we cannot wonder that we derive 
so little benefit from this measure. The best authorities discard 
this remedy altogether, or employ it only in the very onset of the 
disease, when the congestion of the meninges is so intense as 
manifested by convulsions, coma, or delirium. On the whole, it 
will perhaps be better to attempt to subjugate these alarming 
symptoms by other remedies, and save the patient from the ad- 
ditional exhaustion which the abstraction of blood is likely to 
entail, since the disease naturally has a tendency jper se to assume 
an asthenic form, and the patient is liable to die from exhaus- 
tion. Dry cups, applied along the spine repeatedly, act as a re- 
vulsive by withdrawing the blood fi-om the engorged vessels of 
the cerebro-spinal centres, and have the additional advantage that 
the child does not thereby lose any blood. Various irritating reme- 
dies are also applied along the spine, such as sinapisms, turpen- 
tine, ammonia, and the like. Many German physicians recommend 
the use of ice in bladders to the head, and along the spine; but 
as this remedy has a tendency to act as a depressant upon the cir- 
culation, not much if any benefit can be expected from it ; better 
results have been obtained from hot water applied by means of a 
sponge along the spine. Where constipation exists, a dose of calo- 
mel or some other active purgative should be administered at the 
commencement of the disease. Bromide of potassium or sodium is 
now admitted to be of great benefit in this disease, for the purpose 
of averting convulsions, and of subjugating them when they have 
already attacked the patient. In the latter case the remedy should 
be given in large doses, say five to ten grains every ten or fifteen 
minutes to a child two to three years old. I have seen chloral, ad- 
ministered per rectum, act like a charm in controlling the convul- 
sions. For the great restlessness and sleeplessness, morphine or 
chloral is indicated. For the purpose of acting upon the hypere- 
mia and vascular engorgement, ergot has been found to be an efii- 
cient remedy, especially during the early stage of the disease, and 
should be given in full doses. Later on iodide of potassium is 
prescribed for the purpose of causing absorption of the exudation 
within the cerebro-spinal cavities. All authorities agree that qui- 
nine does not exercise any great curative influence upon the disease. 
The diet should be light and nutritious, such as milk, eggs, and 



MIASMATIC DISEASES. 5O5 

the like. After the fever has abated, and the powers of the system 
begin to fail, stimulants will be necessary. That the patient is to 
be guarded against all excitement and disturbances it is scarcely 
necessary to say, since the least annoyance, even a strong light, is 
likely to aggravate his condition.] 

(6.) Cholera Asiatica. — The history, epidemic character, man- 
ner of propagation, and etiology of epidemic cholera, have of late 
been so thoroughly investigated, that we may very properly omit 
them altogether here, especially since cholera Asiatica in children 
has manifested no peculiarities. But the symptoms which attend it 
in children differ materially from those manifested in the adult, and 
it is this difference only which we will here consider. 

Since diarrhoea in general is extraordinarily frequent in small chil- 
dren, and is constantly reproduced by the irritation of improper food 
or dentition, it is therefore still more difficult to decide in them than 
in adults whether a diarrhoea originating during the prevalence of an 
epidemic of cholera is to be attributed to cholera-poison or to the 
above-mentioned ordinary causations. It is certain that, during an epi- 
demic, all children, even nurslings, are more predisposed to diarrhoea, 
and that it is more difficult to arrest it, than during periods free from 
epidemic influence. Diarrhoea thus induced may either continue as 
such for a long time, and be arrested after many weeks, without any 
additional serious symptoms having become superadded, or it may 
pass into real cholera. In many cases, however, no diarrhoea at aU 
precedes, and very healthy children are suddenly attacked by profuse 
purging and vomiting, and in a few hours display the most perfectly- 
developed cholera, with profuse bright-yeUow discharges, cramps, dis- 
appearance of the pulse, algor, cyanosis, and suppression of urine. 
The discharges are seldomer of the rice-water character than in adults. 

Two stages may also be distinguished in children : (1.) The stage 
of the attack, and, (2.) The stage of reaction. Few children, how- 
ever, reach this stage, most of them perishing during the attack. The 
secondary processes and the exhausted condition belong to the phe- 
nomena of reaction. In general, however, three principal classes of 
phenomena may be distinguished in cholera : (1.) Those belonging to 
the intestines ; (2.) Those of the circulation and respiration ; and (3.) 
Those of the kidneys. 

(1.) By far the most important are the derangements of the intes- 
tinal mucous membrane ; they are invariably the first to appear, and 
probably are the causation of the alterations of the circulation, and 
very certainly of those of the kidneys. 

It is a remarkable circumstance that the stools of children seldom 
become as white as those of the adult, but almost always retain a 



506 DISEASES OF CHILDREN. 

yellowish tint ; in other respects, they present neither chemical nor 
microscojDical modifications worthy of note. They are rarely very 
copious, but five to six thin evacuations in an infant suffice to induce 
the most dangerous collapse. In previously marasmic children, col- 
lapse may supervene even after the first thin passage, followed by a 
few convulsions, and in a few hours by death. When the stools be- 
come pink red, a coloring due to a small admixture of blood, the prog- 
nosis may be set down as absolutely hopeless. 

No child under one year of age is able to resist a profuse cholera 
purge longer than forty-eight or at the utmost sixty hours, death tak- 
ing place in consequence of the enormous loss of the fluids of the 
body. But when the discharges are seen to grow less and more in- 
frequent, then more yellowish, more solid, and assume an intense but 
not an actually fetid odor, a favorable prognosis may be given. 

As respects the vomiting in the cholera of children, there is a 
marked difference from the adult. In the latter, it is observed in 
nine-tenths of the cases, in the majority of cholera children not at all, 
or at the most once or twice, and the profuse vomiting of every 
thing shortly after it has been introduced into the stomach scarcely 
ever occurs in such children, a fact that is the more remarkable, 
as children in health vomit oftener and easier than adults. The 
act of vomiting is accomplished by a very slight exertion only : the 
food last taken is first thrown up, and soon followed by the real tran- 
sudation from the gastric mucous membrane, generally mixed with 
the drinks, which, on account of the tormenting thirst, are constantly 
swalloAved in large quantities. In regard to the chemical properties 
of the matter vomited by cholera children, but little, so far as I am 
aware, is kno^vn, because it is always ejected on to the garments or 
bed, and cannot therefore be obtained in sufficient quantity for proper 
chemical examination. 

The absorbing function of the gastric and intestinal mucous mem- 
brane is very much diminished during the attack, and for that reason 
large quantities of toxic substances, such as morphine, strychnine, 
belladonna, etc., may be administered without producing their normal 
effect ; sometimes, however, when the transudation already happens to 
be undergoing spontaneous diminution, dangerous absorption sud- 
denly takes place, and attention on this account is here called to that 
point. As this class of remedies is repeatedly selected for new thera- 
peutic experiments, it is well for the experimenter to know that, 
deceived by the first dose, appearing to be inert, he may suddenly 
find it to have produced a poisoning, and to have destroyed the last 
Qope of the recovering child. 

Soon after the commencement of cholera, the abdomen quickly col- 



MIASMATIC DISEASES. 50^ 

lapses, and becomes so soft and flabby tbat the intestinal coils may 
be recognized. Percussion shows tbat the stomach contains a toler- 
ably large quantity of gas, while the whole intestinal tube is filled 
with transudation, and therefore a perfectly dull sound is produced. 
The patients seem to suffer less from true colic than from a feeling of 
incessant nausea, which they manifest by frequently opening the 
mouth, protruding the tongue in a peculiar manner, and an anxious 
expression of the countenance. 

It is a remarkable fact, that the most profuse diarrhoeas of cholera 
Asiatica do not redden the anus, while, on the contrary, in enteritis 
folliculosa, or the effects of thrush, it becomes red and eroded after a 
few evacuations. 

The next effect of this transudation, and the complete abolition of 
the function of absorption, is, naturally, a marked diminution of the 
whole volume of the blood, and a disappearance of the fluids from the 
parenchymatous organs and serous sacs. Whether all subsequent symp- 
toms are induced by this diminution of the blood and fluids, or whether 
the poison of cholera produces a specific action, in some other place 
besides the intestinal canal, are still undecided questions. The course 
is so extremely rapid in children, that a direct action of the cholera- 
poison upon the heart and pulse seems probable, as sometimes the 
pulse and the diastolic sound of the heart disappear almost with the 
first liquid passage. 

(2.) During the first few hours of the cholera attack, the circula- 
tion is said to be increased in activity, accompanied by violent palpita- 
tion of the heart, and intense beating of the arteries ; usually, however, 
the impulse of the heart, and of the radial pulse, become weaker 
hourly from the very commencement, and the latter soon disappears 
altogether, while the cardiac sound continues to grow weaker and 
duller, till the diastole alone is heard over the large vessels, even after 
it is imperceptible over the apex itself. 

The pulse, in children under one year old, retains its normal fre- 
quency; generally it is about 100 in the minute; soon, however, it be- 
comes thready, and then disappears altogether. The observations 
w^hich tT. Meyer made in the adult — to the effect that the pulse, in cases 
of spontaneous reaction, remains absent for a long time, but after it has 
once returned does not readily disapjDcar again ; and that, on the other 
hand, in cases where reaction was induced artificially by stimulants, 
the pulse acts reversedly — are equally true of cholera of children. Very 
frequently it is possible, by a high temperatvu-e, a mustard-bath, or a 
camphor-powder, to restore the pulse, it is, however, very seldom pos- 
sible to preserve it ; it soon disappears again, never to return. On 
the whole, it may be observed that pulseless children, when this state 



508 DISEASES OF CHILDREN. 

has existed for several hours, are generally lost, while there are many 
instances recorded of adults who have been pulseless for from twelve 
to twenty-four hours, and even longer, and have nevertheless recovered. 
In cholera t}^hoid, various anomalies of the pulse, such as intermit- 
tent and extremely-rapid pulses, occur ; a very slow pulse, even forty 
to fifty in the minute, the like of which is only met with in hydro- 
cephalic children, is not a symptom inconsistent with a favorable 
prognosis. 

The veins are turgid with semi-fluid, grumous blood, on account of 
the tardy venous circulation, resulting in part from enfeebled vis a 
tergo, and in part also from tlie suction-power of the right side of the 
heart having become enfeebled. This stasis of the capillaries is seen 
in the lips, fingers, and eyelids, as cyanosis. In cholera, well-nourished 
children only become cyanotic, while emaciated and marasmatic chil- 
dren acquire only a correspondingly yellowish-gray discoloration. 

The respiration during such sudden and profound disturbances of 
the circulation very naturally becomes affected. By physical examina- 
tion, nothing abnormal can be detected in the lungs, but, in the per- 
formance of the respiratory act, changes are soon observed. The child 
breathes irregularly, frequently sighs deeply, and suffers intense dysp- 
noea. But the most remarkable phenomenon of all, is the coolness of 
the breath, which may be distinctly perceived by holding the hand, es- 
pecially its dorsal surface, over the mouth. Prognostically this cool- 
ness of the breath is of the greatest importance, and is palpably the 
most distinctive sign of the arrest of the metamorphosis of the tissues. 
With this, the coolness of the extremities always stands in direct re- 
lation. Palpation of the nose, forehead, hands and feet, as well as 
the temperature of the expired breath, with a warm hand, will be suf- 
ficient to enable the experienced physician to form an opinion as to 
the severity of the disease, and its probable termination. 

(3.) The morbixi changes of the kidneys are as constant in children 
as in adults. The autopsy discloses the signs of stasis and acute 
Bright's disease. It is, however, impossible in most cases to discover 
these facts by an examination of the urine during life, because the 
patients either do not pass any urine at all, or it dribbles away from 
them into the diaper, and cannot be obtained for examination. When 
children recover from a severe attack of cholera, as they occasionally 
do, albuminuria and casts will be found. How long the secretion of 
urine may be arrested, and yet recovery follow, it is difficult to say, 
for the diapers are incessantly wetted with the profuse stools, so that 
an admixture of urine cannot easily be recognized. 

In consequence of the arrest of the secretion of urine, a violent 
revolution in the entire metamorphosis of the tissues very naturally 



MIASMATIC DISEASES. 509 

eusues, and the retention of the urates must be regarded as the main 
effect of this condition. The tonic and clonic spasms, at least of the 
face, bj which all cholera children are attacked, are most probably at- 
tributable to it, while the great exhaustion, the rapid collapse, and the 
aphonia, are due more to the speedy loss of the serum than to any 
other cause. 

When children recover from an attack of cholera, the first urine 
passed contains albumen, and is rendered opaque by the urates ; a 
cholera typhoid then develops itself, in which the skin becomes hot and 
dry, the pulse hard and extremely frequent, the tongue inclined to dry 
ness, and the symptoms of cerebral congestion come on. In many 
cases, however, death is caused by convulsions, while in others marasmus 
develops itself, from which but few children escape with their lives. 

If we subject the symptoms of cholera in children to a resume, we 
find the following variations from those of the adult : 

(1.) The stools remain yellow for a long time. (2.) Collapse comes 
on very rapidly in feeble, atrophic children, and death ensues before 
many colliquative stools have passed. (3.) Vomiting is rare, and in 
many instances absent altogether. (4.) The comparative mortality is 
much greater ; at least eighty per cent., of the children who become 
cool and pulseless, perish. 

The pathological anatomy, which in cholera is generally very 
meagre, exhibits nothing peculiar in children. In those who suc- 
cumbed early in the attack, the following conditions are found, viz, : 
a peculiar tenacity of the serous membranes, dryness of all the pa- 
renchymatous organs, cyanosis of the skin, black masses of grumous 
blood in the veins and heart, the small intestines filled Avith a whitish 
fluid, their mucous membranes a rosy tint and completely denuded of 
epitheKum, the kidneys infiltrated, the urinary tubules revealing ex- 
tensive desquamative catarrh, and the bladder empty. 

If, on the contrary, they died from cholera typhoid, the cyanosis of 
the skin is less marked, the serous membranes are still glutinous, the 
brain is oedematous, lobular infarctions are frequently found in the 
lungs, the small intestines contain a thick, tenacious, greenish mucus, 
their mucous membranes are less infiltrated and injected, and the soli- 
tary glands of the large intestines are swollen or ulcerated. The 
bladder now contains a little opaque urine, in which generally albu- 
men may be detected. 

Treatment. — The therapeutics of cholera in children, as may be iu- 
Terred from the relative mortality, is extremely unsatisfactory, though 
the most important part of the treatment, the artificial maintenance of 



510 DISEASES OF CHILDREN. 

the temperatiire, is more easily effected than in adults. The gen- 
eral discussion of its prophylaxis may be properly omitted here, as 
this has lately been very minutely described in various text-books, for 
example, in Grlesingefs Infecting Diseases. The treatment of cholera 
diarrhoea, and of cholera in children, differs but little from that practised 
in the adult. The attempts to check the purging in any manner, as 
soon as the stools have become watery, bright yellow, or, still worse, 
rice-watcr-hke, prove totally fruitless. For simple diarrhoea of teeth- 
ing, which, during the prevalence of an epidemic of cholera, must al- 
ways excite the greatest anxiety, laudanum will alwaj-s prove the 
most reliable remedy ; but, if true cholera come on, no benefit what 
ever, according to my experience, need be expected from it. The tinc- 
ture of opium may be given in from four to five times the usual doses. 
Should the diarrhoea, however, continue imchanged, as it often does, 
or if it have existed for one or two days before the narcotic was 
administered, it may suddenly be arrested, and be followed by the 
most violent signs of narcotism. Astringents, and especially all 
those remedies to which any constipating effect has been ascribed, 
are useless. 

It should be borne in mind that, in consequence of the profuse 
exosniotic current, which takes place toward the mucous membrane 
of the stomach and intestinal canal, no absorption whatever probably 
occurs. In the next epidemic, therefore, I intend to select some other 
places, which seem to be more disposed to absorption, for example, 
the bladder, urethra, and vagina, and try different remedies, espe- 
cially of the class of narcotics. Injections into the veins are very 
difficult to perform, OAving to the smaUness of the vessels in children, 
and this practice will hardly ever be successful, on account of the dan- 
ger of admitting air into them. 

As regards the diet and regimen, it should be clearly stated that 
the proscribing of drinks, by which it is intended to check the pro- 
fuse diarrhoea, is totally useless and cruel. Children certainly ought 
not to be allowed too much at one time, but they may drink as 
often as they feel thirsty. Large quantities of fluids, when swal- 
lowed rapidly, are liable usually to cause vomiting. Children prefer 
cold water to every thing else, and the mn-sling will draw actively 
at the mother's breast as long as its strength will allow ; and, when 
it has become too feeble, will swallow the milk taken from the breast 
of the mother with avidity. An administration of other nutriment, 
except plain demulcents or lukewarm milk, is, of course, altogether 
out of the question ; warm chamomile and peppermint teas are re- 
jected by most. 

The principal indication is, manifestly, an artificial continuous 



MIASMATIC DISEASES. 511 

warming of the chilled surface of the body, which is best accom- 
plished by placing the child in a hot-water bath of 30° Reaumur 
(100° Fahr.), in which one or two ounces of ground mustai*d are 
suspended. The skin thus reddened should be dried quickly, the 
child then put to bed, and surrounded by bottles filled with hot 
water, and the diapers should not be changed oftener than once in 
two hours. By keeping up a high temperature, the pulse that has 
-totally disappeared sometimes becomes again perceptible, the diar- 
rhoea diminishes, the tip of the nose, the ears, and the breath, be- 
come warm, and a reaction sets in, which, even then, very frequently 
indeed, terminates in a fatal typhoid condition. 

The most important indication in the typhoid condition is the 
frequent administration of drinks, in order to restore the occluded 
passages in the kidneys, and render them again permeable. The 
nervines, such as camphor, musk, coffee, etc., and the so-highly- 
lauded quinine, seem to me to have no favorable effect upon the 
course of this disease. 

During convalescence, the utmost caution will have to be ex- 
ercised so long as any abnormal changes whatever can be detected 
in the stools. 

Children at the breast should retain their wet-nurses from six 
to eight weeks after the attack of cholera, and should be weaned 
very gradually ; those brought up by hand should be fed upon 
mucilaginous soups for a long time, and slowly habituated to a 
milk-diet. 

Consoling and important as the prompt and efficient services of 
the physician may be regarded, it is problematical whether all his 
therapeutic measures are of the slightest use to the child with 
cholera, 

[Recent researches by Koch and others have shown that cholera 
is due to a germ, the result of decomposition of vegetable mat- 
ter. This germ has been denominated cholera-bacilli, and by 
Koch as comma-bacillus, owing to its resemblance to the comma. 
This micro-organism is supposed to be introduced into the sys- 
tem by drinking water contaminated with decomposed vegetable 
matter held in solution. Koch claims to have succeeded in cul- 
tivating the bacilli artificially, and of having produced the dis- 
ease in animals by the administration of this artificially produced 
cholera morbific matter. Grassi * claims to have found the com- 
ma-bacilli in the stools of persons suffering from choleraic diar- 
rhoea or cholerine ; and Emmerich, of Munich, asserts that he has 

* New York Medical Record, December, 1884. 



512 DISEASES OF CHILDREN. 

discovered a micro-organism of the blood and tissues of persons 
affected with cholera. This bacillus was present in the blood and 
internal organs in nine autopsies, and in the blood of one living 
cholera-patient. According to Koch, the cholera-bacillus " is fa- 
vored in growth by alkalies and killed by acidity or dryness." 
They are of a very low grade of vitality, and three hours of dry- 
ness is sufficient to kill them. The disease is disseminated by the 
germ being carried from place to place by travelers, or fomitne; 
such as rags, etc. 

As regards the treatment, Koch gives it as his opinion that 
opium is still the best remedy for the early stage of the disease, 
and most writers on this subject indorse his opinion. Prof. Sam- 
uel, of Prussia, recommends the "subcutaneous injection of a warm 
saline solution, that being preferable, in his opinion, to injections 
into the veins ; in the latter condition the fluid injected is quickly 
lost." In one case reported by him, he injected seven ounces of the 
solution, followed by four and a half ounces more, with excellent 
result. The fluid should be injected into the subcutaneous tissue 
of the chest and arms. The injection of quinine into the veins, 
as well as the application of ice-bags to the spine, have proved 
to be totally useless. The same is true of calomel and cold effu- 
sions. 

In the recent epidemics of cholera in Marseilles and Toulon, 
laudanum with ether, and ice in the mouth for checking vomit- 
ing, were I'elied upon for the first stage ; in the second stage 
equal parts of acetate of ammonia and alcohol were administered 
internally, and morphine was used hypodermically ; also frictions 
of the body and limbs with spirit of turpentine or some other rube- 
facient. 

Dr. Manfredi has studied the action of tannic acid upon chol- 
era-bacilli, and finds that even in small amounts it kills them. He 
therefore recommends the rectal injections of solutions of this 
drug. Cantani recommends the same method, and gives the fol- 
lowing formula : 

1^. Aqua destil., O iv. 

Acid tannic, 3 jss.- 3 iij- 

G. Arabic, § jss., 

Tr. opii, gtt. xxx-1. M. 

Prof. Alberta Hiva, as the result of experiments upon animals, 
thinks that saline injections into the peritoneal cavity may be bene- 
ficial in cholera. 

Dr. Panier recommends the heroic use of strychnia throughout 
the whole course of cholera. He gives hourly about -^ gr. of sul- 



MIASMATIC DISEASES. 513 

phate of strychnia to an adult. MM. Huchard and Dvjardin- 
Beaumetz recommend the hypodermic injection of caffeine dis- 
solved in a solution of benzoate of soda. The dose given is about 
gr. ss. to an adult. 

Dr. Reddle, of Partabgark, India, employed injections of small 
doses of chloral hydrate, and claims to have lost only thirty-five 
per cent, of his cases, while under other methods of treatment the 
mortality was sixty-four per cent.* 

(7.) Whoopikg - Cough {Tussis Convulsiva — Pertussis). — 
Whooping-cough is an epidemic, contagious bronchial catarrh, 
with peculiar convulsive paroxysms of cough. Hippocrates has 
not described it accurately. The delineations of the epidemics of 
the former centuries are not exactly applicable to the group of 
symptoms as it is now observed, and only since the eighteenth 
century have more correct views been entertained in regard to 
this disease in the different countries where it has prevailed. Be- 
sides the denominations above given, it has received a number of 
others, such as coqueluche, affection pneumo-gastrite-pituiteuse, 
broncho-cqyhalite, catarrh convidsif (in France) ; chin-cough (Eng- 
land) ; pertussis, tussis siffocativa, spasmodica, strangulans, clan- 
gosa, ferina, hlauer Uusten (blue-cough), Schaafshusten, Esels- 
husten (Germany). We have to deal here with no simple anatomo- 
pathological alteration, but with an acute cosmical disease, and, in 
fact, from the class of the so-called atmospheric pestilences. 

Symptoms. — Three stages of whooping-cough can be distin- 
guished with tolerable accuracy : 

(1) A stadium catarrhale ; (2) a stadium convulsivum ; and 
(3) a stadium decrements 

(1.) Stadium. — The phenomena of the stad. catarrhale, or pro- 
dromorum, or invasionis, are those of a simple bronchial catarrh, 
sometimes complicated with gastric symptoms. Some hoarseness, 
tickling of the throat, dry cough, sneezing, profuse flow of mucus 
from the nose, lachrymation and redness of the eyes, are together or 
singly observed in almost every child with commencing whooping- 
cough. If febrile symptoms supervene, as frequently happens, such 
as hot skin, frequent pulse, depression, general malaise, and loss of 
appetite, then we have a perfect picture of the stage of incubation 
of measles, a fact which, when whooping-cough and measles prevail 
simultaneously in one place, we shall do well to keep in mind, on 
account of its bearing on the prognosis. The cough, from the very 
commencement, assumes a peculiar, hollow, metallic clang, soon 

* Op. cit. 



514 DISEASES OF CHILDRE>r. 

becomes paroxysmal, and, if no preexisting pulmonary affections are 
present, is always totally dry. This stage lasts from three days to 
three weeks, is more or less distinctly marked, and can be observed 
in every case of whooping-cough. 

(2.) Stadium. The stad. convulsivum or 7iervosum is distinguished 
by the cough recurring in violent paroxysms, and which is of such a 
peculiar character that it is never forgotten again when it has once 
been heard. Somewhat older children have a premonition of the 
occurrence of the attack. Tliey experience a tickling sensation in the 
throat, ©Impression of the chest, feel nauseated, breathe anxiously and 
qviicklj^, sit upright in bed, or run, when they are awake, to a chair or 
some other support, in order to be ablg to offer a stronger resistance 
to the attack. The paroxysm itself consists of a great number of 
short, rapidly-recurring, not perfectly uniform, spasmodic coughs, and 
is at length interrupted by a protracted, whistling, sipping attempt at 
inspiration. The French designate this whistling inspiration by the 
word " reprise." Immediately after the first one, the convulsive ex- 
pirations begin anew, last ten to fifteen seconds, whereupon another 
" reprise " follows, and thus these two acts alternate with each other 
several times in such a manner that an entire paroxysm, from the be- 
ginning to the reappearance of the normal respiration, may last from 
one to fifteen minutes. At the beginning of the paroxysm, the single 
cough-exclamations follow each other with the greatest rapidity, and 
without any interv'als, and the child seems to be in imminent danger 
of dying by suffocation. And in fact, during the fit of coughing up to 
the " reprise," no air whatever gains entrance into the lungs, a fact of 
which one can easily convince himself by auscultating the dorsal 
surface of the thorax. At the " reprise " the glottis is evidently in a 
state of momentary constriction, either in consequence of spasm, or of 
paralysis, as has been already more thoroughly explained during the 
study of croup, and all the auxiliary respiratory muscles of the neck 
and abdomen are called upon to perform an active part. Serious stag- 
nations of the circulation are produced by the choking acts of cough- 
ing ; the blood stagnates in the pulmonary artery, and then occasions 
dilatation of the right side of the heart and of the entire peripheral 
venous system, a condition that is especially distinctly to be seen in 
the large veins of the neck. Finall}^, the children become bluish red 
over the entire head and face, from which also the designation of 
" Blauhustens " (blue-cough) has originated. The eyes become in- 
jected, and protrude somewhat from their sockets. The face swells 
up, and is covered with a cold perspiration ; the movements of the 
heart and of the pulse are feeble and unequal ; the urine and f?eces 
are often involuntarily ejected by the violent contractions of the al> 



MIASMATIC DISEASES. 515 

dominal muscles ; hernia and prolapsus of the rectum are also some- 
times occasioned thereby. The venous stasis gives rise to frequent 
haemorrhages ; the most common are those from the mouth and nose. 
Whether the larger quantities of blood vomited and coughed up come 
from the lungs, as some believe, is very questionable, because very 
often no consecutive alterations of the lungs whatever, and no ag- 
gravation of the general condition, ensue therefrom, and a perfectly 
colorless mucus is expectorated in the paroxysms of cough that come 
on a few minutes thereafter. We know, however, that after an hsemop- 
tysis, for instance in tuberculosis, the sputa continue to be bloody for 
several days. Extravasations of blood upon the conjimctiva bulbi, or 
into the loose cellular tissue of the eyelids, frequently take place, 
where the extravasated blood undergoes the same changes of color 
that we observe in external injuries. JBouchut relates a case where 
a child cried with real bloody tears, and states also that the haemor- 
rhages in pertussis may sometimes become so profuse as to endan- 
ger life, an occurrence that I have never yet experienced. So, too, 
the bleedings from the ears, of which mention is made in most of the 
text-books, I have never observed ; nevertheless I do not doubt that 
they have been seen, especially in cases of otorrhoea, and ulcerations 
of the external meatus. J*. Frank reports a remarkable case of a 
patient who was obliged to sneeze one hundred times or more at every 
paroxysm. Nervous children may be seized with general convulsions 
during these paroxysms of cough. 

Vomiting usually forms the finale of every paroxysm, which, at the 
beginning of this second stage, only results in the expulsion of a little 
mucus, while much liquid food and gastric juice are thrown up. The 
longer the whooping-cough has lasted, and the nearer it approaches to 
the third stage, the more profuse becomes the secretion from the 
bronchi, and, finally, with every paroxysm of cough, partly by the act 
of coughing, and partly by the act of vomiting, a large quantity of 
colorless, tenacious mucus is expectorated. 

When the attacks are of much duration, protracted for ten to fif- 
teen minutes, the children feel very much exhausted after them, com- 
plain of pain in the breast, breathe for a long time anxiously and 
hurriedly, and, finally, fall asleep. Generally, however, when the 
paroxysms are only moderately severe, they forget their sufFeriags 
immediately after they have ceased, and, to the great surprise of their 
inexperienced parents, resume their play, or even their meals. Sim- 
ple pertussis is unattended by fever, but the supervention of fever 
and anorexia always indicates a complication. 

The number of paroxysms in the twenty-four hours varies from 
four to sixty; generally, however, not more than eighteen to twenty- 



516 DISEASES OF CHILDREN. 

four occur during that period. No regularity in the successions, nor 
equality in their intervals, is ever to be observed. They are more 
violent, and occur oftener in the evening, when, generally, various ex- 
ternal exciting causes, such as heating, mental excitement, eating and 
drinking, cooperate. The attacks come on either wholly sponta- 
neously in children who maintain a perfectly quiet attitude, or they are 
induced by crying, mental excitements of all kinds, laughing, swal- 
lowing, particularly the swallowing of dry, irritating morsels, cold 
or impure air, etc. When several children affected with whooping- 
cough are together, and one of them begins to cough, the mere sight 
will, in most instances, infect the rest, and soon all join in this most 
distressing concert. 

In healthy children, and under favorable circumstances, this stadium 
lasts four weeks, but it may, under other circumstances, be prolonged 
for eight weeks, or more. A remission in the severity and frequency 
of the paroxysms, attended by an augmentation of the secretion, in- 
dicates a speedy transition to the third stage. 

3c? Stadium. In this stadium criticum, s. clecrementi, the parox- 
ysms of cough have lost their severity. The paroxysms are not so 
long, and the acts of coughing not so rapid ; the " reprise " ceases 
entirely, and, although retchings may still be present, no liquid food 
is vomited, the vomited matter consisting of an enormous quantity of 
bronchial mucus. This mucus is mostly yellowish or greenish colored, 
and, with every attack of coughing, nearly a tablespoonful is expec- 
torated. About this time nocturnal perspirations become superadded 
in most of the children, and sometimes an eczema also breaks out. In 
healthy children, when the cough has reached this stage, it will cease 
completely in from two to three weeks, but in tubercidous and scrof- 
ulous children, on the contrary, it may still last for many weeks. In 
this stage, short relapses often also occur, and the patient is tin-own 
back into the second stage ; but, generally, these relapses are of short 
duration. 

The complications of this disease are numerous, and, generally, 
they are of a dangerous character. 

Tlie most frequent complication liable to occur is an affection of 
the pulmonary parenchjTtna, which may very readily become developed 
from the retention and decomposition of large quantities of bronchial 
mucus. It usually appears as a lobular pneumonia, only exceptionally 
as lobar pneumonia, and is to be dreaded in proportion to the age 
of the child at which it occurs — the younger, the more dangerous. 
Children under one year of age, who lie much upon the back, and have 
not muscular ability to properly cough up the mucus from the bronchi, 
are extremely often attacked during pertussis with symptoms of 



MIASMATIC DISEASES. 517 

pneumonia, such as hot skin, rapid pulse, frequent, painful breathing, 
accompanied by a loud noise during expiration, and elevation of the 
alae nasi. The paroxysms lose their characteristics, and a dry cough, 
combined with a painful distortion of the countenance, supervenes. 
Most of these children perish in a few days of convulsions and marked 
cyanosis. In a few solitary instances only do the symptoms of the lob- 
ular pneumonia subside and give place to the former pertussis, and, even 
when this occurs, there is always still the greatest danger of relapses. 

Other children suffer from gastric complications. They get a 
coated tongue, anorexia, fever, suffer from general debility, and 
putrid smell of the faeces. The ulceration of the fraenum linguge, long 
known in Germany, is a very peculiar occurrence. Gambarini^ of 
Mailand, has lately recalled the attention of the profession to it. The 
ulcer almost always extends in a transverse direction to the long axis 
of the frasnum, and very often is seen in whooping-cough in children of 
from one to two years of age, never in very young children and seldom 
in older ones. It seems that this condition depends upon a mechani- 
cal cause ; namely, the tongue, in the violent acts of coughing, is thrust 
out forcibly, and the frffiuum is, so to speak, sa^vn off by the sharp 
lower incisor teeth. Hence the reason why it is never met with in 
the stiU toothless infant nor in older children who have already some- 
what blunted their incisors, and who are not in the habit of thrusting 
out the tongue during the attacks. It is, however, absent in a large 
number of severe cases of whooping-cough, and is also observed in 
children with simple bronchitis, as well as in those without any 
cough, in the form of aphthous ulceration, especially during dentition. 
This ulcer does not heal, no matter what treatment be adopted, so 
long as the convulsive cough lasts, but will heal spontaneously as 
soon as a mitigation in its intensity has taken place. 

Again, in other children, marked cerebral symptoms supervene in 
consequence of the venous stasis ; in general, however, this complica- 
tion is much less frequently observed. The children become lethargic, 
frequently carry their hands to the head, complain of severe head- 
ache, and other similar signs, which appear to render the pertussis a 
secondary affair. Grating of the teeth, hydrocephalic vomiting, con- 
vulsions, and coma, finally set in, though death but extremely rarely 
ensues, and when it does there is found a cerebral disease, acute hy- 
drocephalus or purulent meningitis, but which is not directly con- 
nected with the pertussis. 

Other though rare complications are pleurisy, pericarditis, and 
pemphigus. Jadelot saw pemi^higoid vesicles occur in numerous epi- 
demics, and in every instance death resulted. 
.34 



518 DISEASES OF CHILDREN. 

The most frequent sequelae are chronic bronchitis, goitre, hernia, 
prolapsus of the rectum, dropsy, tuberculosis, and aneurism. 

Death, as the direct consequence of an attack, is extremely rare, and 
notwithstanding the numerous severe ejDidemics that I have witnessed 
I am unable to recollect a single instance. On the other hand, the ma- 
jority of the patients affected with pneumonia died, and children under 
one year of age may, even without the superaddition of an acute 
fever, become so atrophic from pertussis as not to be able to rally. 

Wliooping-cough has no power to protect its subjects from any 
other epidemic disease. Pertussis patients may acquire all possible 
diseases, acute exanthemata, intermittent fever, typhus fever, cholera, 
etc. ; but occasionally chronic skin-disease disappears in a very re- 
markable manner while the whooping-cough lasts. 

The diagnosis of whooping-cough is very easy to make. The 
cyclical course, the peculiar cough, with the prolonged, loud inspira- 
tion, the vomiting at the close of the paroxysm, and particularly the 
epidemic occurrence, as well as its often demonstrable contagiousness, 
are such constant symptoms, that their presence leads with certainty 
to the diagnosis. Moreover, a paroxysm may be induced at wiU in 
every child with whooping-cough, by pressing the root of the tongue 
with the finger, a fact which is often very advantageous for clinical 
purposes. The retching thus produced is almost always followed by 
a violent paroxysm of cough, which instantly indicates the true diag- 
nosis where the descriptions of attendants have given no clew to it. 

Pathological Anatomy. — When an apparently healthy child with 
whooping-cough dies in consequence of an injury or some acute dis- 
ease, in the convulsive stage, the air-passages will sometimes be 
found injected, but sometimes again perfectly normal ; but, if death 
occur during the last stage, the trachea and large bronchi are filled 
with that mucus which during life was expectorated in such large 
quantities. Not the least morbid alteration is to be detected about 
the glottis. 

The bronchial glands are sometimes, but by no means invariably, 
swollen. Owing to the supposition, which prevailed for a long time, 
that a neurosis was the cause of this disease, the brain and spinal 
cord, as well as the pneumogastric nerves, were often subjected to a 
thorough examination, but this, in the majority of the cases, proved 
to be perfectly fruitless, and only a few investigators speak of a red- 
ness of the pneumogastric, which most probably is to be regarded as 
a, post-mortem imbibition, for, on account of the rarity of the condi- 
tion, it cannot be regarded as pointing to the cause of pertussis. 



MIASMATIC DISEASES. 519 

The most frequent consecutive effects found are lobular and lobar 
pneumonia, cylindrical dilatation of the bronchi, partial pulmonary 
emphysema, pleuritis, pericarditis, meningitis, and tuberculosis of the 
pulmonary and bronchial glands. 

Etiology. — Whooping-cough is contagious, and attacks an indi- 
vidual hut once. The contagiousness of a disease becomes evident 
when a great number of cases follow from direct contact with persons 
affected. This has so often happened in pertussis as to establish the 
fact, and therefore it is very wrong to attempt, by single cases in 
which ho contact with whooping-cough could be proved, to maintain 
a spontaneous origin for the affection. Indeed, we do not know whether 
the contagion be not so intense as to be transmittible by a third 
person, an adult, for example, himself remaining perfectly well. The 
mUd and feverless character and the long duration of the disease, 
in consequence of which the sick children are much upon the streets 
and in public places, favor contact and communication more than is 
the case in any other contagious disease. Most experienced and 
reputable physicians express themselves emphatically, that genu- 
ine pertussis attacks children only once. The assertion of a few others, 
who claim to have observed it twice in the same person, is probably 
founded upon the circumstance that some tuberculous patients suffer 
from pertussis-like paroxysms, or perhaps they have met with a case 
that, already in its decline, has suffered a relapse. 

This contagious property, and the immunity folloAving therefrom, 
result in rendering whooping-cough almost exclusively a disease of 
childhood. It very rarely occurs in adults, and then mainly among 
the wealthy, who have always been much separated from children, and 
have thus escaped infection. Nevertheless, parents of children with 
whooping-cough, and the nursery-maid, frequently suffer from a 
milder kind of spasmodic cough, which seems to be due to their being 
with the patient, for these persons often are not the least predisjDosed 
to a cough, and lose it as soon as they have absented themselves for 
some time from the infected atmosphere. Infants before the com- 
mencement of dentition are less susceptible than those several months 
older ; still, exceptional instances of perfect whooping-cough occur in 
the former, which usually becomes complicated with lobular pneumo- 
nia and terminates fatally. 

It is not possible to state with certainty of what kind its con- 
tagious principle is. Most probably it is confined to the particles 
of mucus expectorated, which, becoming dry, are diffused in the sur- 
rounding atmosphere, a supposition that also seems to be borne out 
by experience, for, in the last stage, cliildren infect with greater cer- 
tainty. 



520 DISEASES OF CHILDREN. 

The stage of incubation lasts but a sbort time, barely ever more 
than three or four days. 

In addition, its purely nervous contagious character, induced by 
simple imitation, as are gaping, vomiting, chorea, hysterical conwil- 
sions, etc., may deserve attention. The constitution, the manner of 
living, and the season of the year, have no marked influence ujDon the 
origin or prevention of the disease. 

By its contagiousness, then, the epidemic propagation of pertussis 
is brought about, so that in the course of a quarter, or at tlie most 
half of a year, the entire juvenile population, or, at least, the greater 
portion of it, has been infected by this disease. Schools and chil- 
di-en's hospitals are to be regarded as the most prohfic channels for 
its propagation. In the latter institutions in particular, it will often 
rage for years, after it has died out in the cities, for new children are 
constantly admitted for surgical or other internal diseases, and then 
acquire pertussis. 

Treatment. — The prophylaxis consists entirely in the removal of 
the children from the place in which whooping cough is just appearing, 
for a perfect isolation is only carried out with the greatest difficulty, 
and never affords as good a guarantee as an actual change of place 
does. Jenner made the interesting observation, that children recently 
vaccinated escaped whooping-cough, and that vaccination exercised a 
favorable abortive influence on patients. Owing to the circumstance 
that we usually perform vaccination in the first months of life, and 
that young children are less Hable to sicken with pertussis than those 
that are a year or more old, the contingency in which this prophylaxis 
is applicable is a limited one. I have as yet vaccinated only two 
young patients with pertussis, one of which was sick for two, the 
other for three weeks : in both the course was a regular one ; in the 
first the actual paroxysms lasted ten, in the second seven days, so 
that, if six weeks were calculated as requisite for the full course, then 
quite an abbreviation of the process was effected here. The internal 
administration of belladonna^ and the suspending from the neck of 
small bags containing various kinds of strong aromatic substances, 
moschus, camphor, etc., have long ago proved to be totally useless as 
prophylactic measures. 

The rational treatment of the established disease consists in the 
prescribing of an appropriate regimen, in treating the indi^adual 
paroxysms, and in the attempt, by the aid of proper remedies, to bring 
about an abbreviation of the entire process. 

As regards the manner of li%dng, that depends upon the season of 
the yeai*. In winter and during the prevalence of sharp, rough 
winds, the permitting children with whooping-cough to go out is 



MIASMATIC DISEASES. 521 

always hazardous, and often results in inflammatory complications ; 
in summer, on the contrary, the subjects are most comfortable 
through the day when they are out in the free air. The course of 
whooping-cough in winter, where children are for many weeks con- 
fined to the house the entire day, and at the most are only able to 
go out for an hour on a warm noonday, is therefore slower, and 
oftener leaves sequelae than in summer. 

As regards the diet, so long as the process runs a simple, fever- 
less course, no changes need be made, but dry bread and cake, and 
all kinds of dry irritating nutriments in general, are to be prohib- 
ited, because, in their passage over the epiglottis, they infallibly in- 
duce a paroxysm. When febrile complications become superadded, 
an antiphlogistic treatment is called for, and its character is already 
understood. Milk nutriments, and a plentiful supply of lukewarm 
milk, exercise a favorable influence in this disease, while the so- 
highly-recommended althaea and elder-flower teas are totally de- 
spised by most children. 

Concerning the so-much-lauded change of air, a residence in the 
country does not by any means possess that abortive influence that 
is usually attributed to it ; still, sometimes it works quite surpris- 
ingly when the patients are removed to the country in the last stage 
of whooping-cough, say, in the fourth or fifth week. The great 
joy attendant upon the change of place, the altered diet and manner 
of living, seem to at once arrest all signs of the disease, and from 
that time the children are not heard to cough. But, when children 
who have only just contracted pertussis are sent into the country, 
no alteration nor abbreviation whatever is to be observed ; they 
infect the children of the village, who may die of lobular pneumo- 
nia, and thus bring about most unpleasant consequences. 

It has recently been claimed in England and France that keep- 
ing a child in a gas-factory produces the most satisfactory results. 
It cannot now be denied that some children have in this manner 
got rid of their whooping-cough, but it should be added that this 
happened after they had had it for weeks. However, this jDro- 
cedure is only attainable by a limited number of patients, since 
these gas-houses would naturally be willing to admit only a few 
sick children with their mothers and nurses at a time, and carrying 
a child back and forth to a distant gas-house, especially during the 
cold seasons, is attended with more or less inconvenience and risk. 
The experiments which I have instituted to test this matter, by 
keeping whooping-cough childx'cn constantly in an atmosphere of 
benzine, did not accomplish any marked abbreviation nor mitiga- 
tion of the attacks of pertussis. 



522 DISEASES OF CHILDREN. 

As regards the paroxysms, all exciting causes are most scrupu- 
lously to be avoided. The children should be commanded to eat 
slowly and quietly, they should not run nor become heated, and are 
to be spared all mental disturbances so far as it is possible. As the 
witnessing of a paroxysm will also immediately induce one in a 
child suffering from whooping-cough, it is therefore advantageous 
to separate such chiklren whenever it is possible. 

In the paroxysm itself the child is easiest with the neck flexed 
slightly forward, and the hands grasping firmly some stable sup- 
port. In case the child droops its head too far downward, the fore- 
head should be supported by the hand. Occasionally very severe 
and prolonged paroxysms may be cut short by introducing the 
finger far into the mouth, and thereby inducing premature vomiting. 
Churchill advises that, at the beginning of the attack, half a drachm 
of ether or chloroform be poured into the hollow of the hand, and 
held in front of the child's face. I have tried this only once, but 
the child was decidedly averse to the vapors, and the room smelt 
so strongly of chloroform the whole day that its occupants were 
affected with headache, and opposed to its further employment. 
If, at the end of a paroxysm, slight giddiness and stupor ensue, the 
children will be obliged to lie down for some time, and the head 
should be covered with cold compresses. 

To enumerate all the remedies that have been resorted to in 
whooping-cough would consume too much space, and be of little 
benefit, for it is now a conceded fact that remedies, which were 
found to be of decided value in some epidemics, proved totally 
worthless in others. 

The treatment by emetics has been, and still is, most incompre- 
hensibly, much in favor. Emetics were given every day, or, at 
least, every other day, for one or two weeks, and it was believed 
that an abbreviation and mitigation of the attacks were effected. 
To young children the French physicians give their syr. ipecac, to 
the older ones vin. stibiat. The fact that those who extol these 
therapeutic experiments are now very materially reduced in num- 
bers, would, of itself, dissuade me from repeating them. And, be- 
sides, to induce vomiting artificially in a disease which is attended 
by recurring acts of vomiting is, as it seems to me, to say the least, 
entirely superfluous. 

Of the narcotics, belladonna came in use by preference, and of 
this remedy, in particular, has it oftenest and most strikingly been 
observed that its effectiveness is decidedly different in different epi- 
demics. Thus, J. Frank, for example, in one epidemic, derived 
beneficial effects from it, in six others none whatever. I myself can 



MIASMATIC DISEASES. 523 

only find fault with belladonna for the inequality of its prepara- 
tions, on account of which it is necessary to exercise the utmost 
possible caution in increasing the dose. As soon as dilatation of 
the pupils and irritation of the throat ensue, the paroxysms, it is 
true, become decidedly ameliorated ; but these symptoms of poison- 
ing are also of themselves unpleasant. They frighten the parents, 
and in some children, even when the use of the remedy has been 
suspended, complete blindness, giddiness, and critical delirium, 
appear. 

So long as the pupils remained undilated, I have never yet been 
able to detect any mitigation in the paroxysms. The medium dose 
is rad. helladonna, gr. \ twice daily, in the form of a powder. As 
many children do not readily take powders, it is best to employ a 
mixture of ext. belladonna, gr. ij — iv, dissolved in 3 ss. of hitter- 
almond water, of which twenty drops may be given two or three 
times daily. The reproach of uncertainty of action, supposed to 
depend upon the manner of preserving belladonna, is even more 
applicable to the extract than to the powder. In its entire course 
whooping-cough cannot be cut short by belladonna, and a mitiga- 
tion of the individual paroxysms can only be accomplished through 
a poisoning, at the risk of unpleasant consecutive effects. 

Opium has been repeatedly recommended. And what was said 
of belladonna is also applicable to this remedy, only in a still greater 
measure. When given for some time it produces constipation, diffi- 
cult to be overcome, and cerebral congestion. Still, at the climax 
of the disease, when the child has already passed several sleepless 
nights and is extremely excitable, it is a very valuable remedy. 
One to five drops of laudanum, according to the age of the child, to 
be sure, produce several hours of sleep, after which, however, the 
paroxysms recommence with their former severity. 

[I have seen excellent effects produced by chloral hydrate, 
given in doses of from five to fifteen grains pro die, according to 
the age of the child. An excellent combination is chloral hydrate 
and bromide of sodium. Less of the chloral proportionately is 
required to produce an impression when given in combination with 
the bromide.] 

Some physicians, in addition, extol ext. conii, hyoscyami, lactucce 
virosce, pulsatillai, nicotiance, and aq. amygdal. amar., which are 
rejected by others. In those whooping-cough epidemics which I 
have so far had an opportunity to witness, I have repeatedly observed 
that the continued use of narcotics for several days, in the early part 



524 DISEASES OF CHILDREN. 

of the disease, only caused harm, while, at its climax, a single or 
repeated narcotism, with opium or belladonna, exercised a favorable 
influence upon the exhausted and yet excitable children. 

The opposers of these narcotics recommend the metallic antispas- 
modics. Their extollers very naively say that, with them, a rapid 
mitigation of the violent cough is less surely effected than a gradual 
extinction of the convulsive character is achieved, and then only is 
a cure effected ; or, in other words, whooping-cough cannot be 
hindered much in its regular course by these remedies. Of this 
class the most preferred remedy is zinci oxidat., 3ss. — 3 j pro die ; 
next, carhonate of iron, 3j — 3ij pro die ; acetate of lead, nitrate 
of bismuth, sxdphate of copper, and, lastly, nitrate of silver. 

The most frequently employed vegetable and animal nervines 
are moschus, castoreum, asafcetida, succinate of ammonia, and 
lastly coffee. 

Tonic and astringent remedies are of decided benefit in the last 
stage of pertussis, and here the powdered cinchona-bark is superior 
to all the rest. In this stage I give to very many feeble children as 
much of the powder as can be taken upon the point of a common 
table-knife two or three times daily, without any admixture what- 
ever, and find that they take it without much objection, and for 
that reason employ it in preference to the decoction, and the alto- 
gether too-bitter quinine. Also tannin, by itself, or in equal parts 
with the flowers of benzoin, given as high as five grains a day, is 
much praised by some physicians. The equally-bad taste, and espe- 
cially the constipating effects that invariably result from its repeated 
employment, are the great objections to it. 

Cochineal, a purely empirical remedy, is tolerably extensively 
used by English practitioners, who, according to perfectly reliable 
reports, claim to have produced some very remarkable effects by 
it in some epidemics. On account of its being easily decomposed, 
it is best to give it in powder mixed with a little sugar, two to six 
grains pro die. My experiments, performed with it in two epi- 
demics, furnished entirely negative results, and, owing also to the 
article being somewhat expensive, I have now abandoned it alto- 
gether. During the last two years, I have made somewhat exten- 
sive use of a remedy that has fallen into mucli disrepute, namely, 
calomel. I give it daily to all whooping-cough patients under one 
year of age, in doses of one-eighth of a grain for two or three weeks, 
until the severity of the paroxysms diminishes. Since that time I 
have observed a far less number of cases of lobular pneumonia, 
which previously carried off a considerable number of the infants. 



• MIASMATIC DISEASES. 525 

Consecutive effects, whether immediately or later, do not ensue 
from this treatment. 

The rest of the empirical internal remedies to be mentioned are, 
sulphur, lobelia inflata, viscum quercinuni, muriatic acid j and, 
lastly, arsenic, phosphorus, and tr. cantharidis. 

The endermic treatment with ung. tartar, stihiat. is now com- 
pletely abandoned, as cruel and ineffectual. Lachmann^s method, 
on the contrary, seems to deserve a further trial. He claims that, 
in the first stage, whooping-cough may abort by vaccination, and, 
in already- vaccinated childi-en, strews the powder of a vaccine crust 
upon a blistered surface, where it is confined for several days by 
adhesive plaster. It is asserted that blisters treated in this manner 
cause severe pain, and occasionally even become gangrenous. He 
also administers the powder internally, a vaccine crust being rubbed 
up with sugar of milk, and repeats this dose after four days, 
by which treatment equally rapid cures are claimed to have been 
achieved. 

Lastly, there remains yet to be mentioned TFafeo?^'s repeated 
and laborious cauterizations of the mucous membrane of the fauces 
and larynx with a solution of nitrate of silver, by which it is claimed 
that the affection is subdued in from eight to ten days. With us, 
they have not proved themselves of such decided efiiciency as to 
have obtained general recognition. 

It is certainly preferable to use such caustics by inhalations, by 
raeans of the simple inhalers now so much in vogue. Rhon causes 
children old enough to use this apparatus to inhale a dilute solution 
of nitrate of silver (gr. j, aqua | ij), from which he claims to have 
obtained a decided diminution of all the whooping-cough symptoms 
after eight or ten inhalations, leaving behind only a simple bron- 
chial catarrh. 

If now, as a resitm'e, I were to give an explanation of my views, 
it would go to show that there never has been, and most probably 
never will be, a remedy by which whooping-cough may be abridged, 
any more than we are able to cut short the acute exanthemata, or 
typhus fever, or pneumonia. Hence, an expectant treatment is to 
be continued as long as possible ; the violent pai-oxysms should be 
palliated by narcotics ; lobular pneumonia in infants we must try 
to prevent by small doses of calomel ; feeble children are to be 
treated with tonics, and, as a general rule, all the patients should be 
kept under the most favorable hygienic conditions possible. 



526 DISEASES OF CHILDREN. 



PAROTITIS COyTA GIOSA. 



(8.) Inflammation of the Parotid Gland {Parotitis). — There 
are three kinds of parotitis : (a) idiopathic, {h) secondary, and (c) 
metastatic parotitis. 

(a.) Idiopathic parotitis occurs only in an epidemic form, and, 
on account of its general spreading, and the almost comical aj^pear- 
ance which it gives to the patients, has received a number of, in 
part, scurrilous names, such as tnumps^ clow7i's disease, Ziegenpeter, 
etc. It has many analogies to the acute exanthemata, attacks a 
person but once in his life, occurs most frequently in the youthful 
age, and has a tolerably well-marked cyclical course. Children 
under one year of age are scarcely ever affected with it. It prevails 
most frequently in the spring of the year, sometimes also in the 
autumn ; and on the damp coasts of Holland, England, and France 
it is said to be endemic. 

Symptoms. — Usually, a few prodromes precede the mumps. For 
one or several days the children feel tired, are ill-humored, fever- 
ish, lose their appetite, and voluntarily betake themselves to bed ; 
indeed, nervous children also manifest cerebral symptoms, head- 
ache, delirium, convulsions ; ravenous children throw up their last 
undigested meal. After one, at the most two or three days, 
they begin to feel pain under one ear, which becomes markedly 
aggravated on opening the mouth, mastication, or extei'nal pressure. 
A swelling is at the same time discovered in the parotid region ; 
fii'st, the depression between the lower jaw and mastoid process 
becomes filled out, and in its place a tumor is found, which pushes 
the lobe of the ear outwardly, and extends beyond the boundaries 
of the gland. The subcutaneous cellular tissue of the corresponding 
cheek up to the lower eyelid, and of the neck, becomes infiltrated 
with serum, so that the movements of the lower jaw and all the 
mimical movements of the facial muscles upon the affected side can- 
not be performed. The induration is situated at the place where the 
gland itself lies, is most marked there, and decreases peripherically, 
The external swelling is tolerably soft and doughy ; the pressure 
of the finger leaves a pit. The integument covering the tumor is 
slightly inflamed. Frequently only one parotid swells up ; when 
both are affected, they are not usually attacked simultaneously, but 
one is generally a few days after the other ; nor is it necessary that 
both should attain to an equal size. At the acme of the disease the 
patients are totally unable to open their mouths, and speak but 
very indistinctly ; the salivary secretion is seldom diminished, often 
somewhat augmented, occasionally profuse ptyalism also occurs, but, 



MIASMATIC DISEASES. 527 

on account of the absence of ulceration of the mucous membrane 
of the mouth, it does not diffuse the disgusting fetor of mercurial 
salivation. As very rare complications, angina tonsillaris, and pha- 
ryngitis, may be mentioned. Suffocative attacks very seldom occur 
here, because the swelling extends outwardly and not inwardly. In 
most cases the affection of the general system is of but short dura- 
tion, and slight. So long as the swelling is extensive, hard, and 
painful, it will, in most instances, be attended by fever ; but, by the 
third or fifth day, the local trouble only will be present. The swell- 
ing of the testis, in adults, frequently that of the same side, already 
observed by Hij)pocrates, on the whole, occurs extremely infre- 
quently : for instance, in the epidemic which prevailed in Munich, 
in 1857, where certainly several hundred men were affected, it was 
seen but once, so far as I am aware. 

Nor have I ever seen the other metastases, to the cerebral menin- 
ges, to the serous sacs, to the bronchial and intestinal mucous mem- 
branes ; still, I do not venture to deny them altogether, for it is well 
known that in some epidemics great variations of the same disease 
may take place at different times. If our followers should witness 
an epidemic of parotitis, to which the description of our contempo- 
raries is not exactly applicable, it is to be hoped that they will at 
least have so much consideration as not to regard our present deline- 
ation as j)urely inventive. 

Course and Termination. — The course of an epidemic idiopathic 
parotitis is almost un exceptionally favorable. After the affection 
has been growing worse for from two to live days, the fever, and 
with it the swelling, begins to subside, and by the tenth or the four- 
teenth day all the general and local symptoms have disappeared 
completely. Complete resolution of the swelling almost always 
takes place ; in some scrofulous children this is somewhat longer in 
being accomplished : the parotid gland and the lymphatics surround- 
ing it are for some time hypertrophied and indurated. Suppurative 
degeneration of the gland does not seem to have been so rare in 
former epidemics as at present. The abscess may burst either directly 
outward, or into the external meatus auditorius, when otorrhoea and 
hardness of hearing will remain for a long time, and, in cases where 
the tympanum has been perforated, life-long deafness will be the 
result. When the chronic indurated gland comes to press upon the 
facial nerve, or if the nerve becomes involved in the suppurative 
process, temporary or permanent motoric facial paralysis will en- 
sue. The prognosis, according to what has been said, is ex- 
tremely favorable. At the beginning of an epidemic, the physi- 
cian has an opportunity to see many cases of mumps, but, after 



528 DISEASES OF CHILDREN". 

several weeks, the public become so thoroughly convinced of the 
utter harmlessness of the evil, that most parents seek no medical 
advice at all. 

Pathological Anatomy. — The pathological anatomy of this dis- 
ease, on account of its being so rarely fatal, is somewhat meagre. 
I have never yet had an opportunity to make a post-mortem exami- 
nation on a case of parotitis epidemica. Bamberger reports as fol- 
lows in relation thereto : The whole gland appears enlarged and 
reddened, its tissues are swollen and flaccid, for primarily a fibri- 
nous exudation of various grades is deposited in the interstitial sub- 
stance that connects the acini of the gland with each other, and in 
the cellular tissue surrounding the gland. In severer forms, the 
inflammation attacks also the glandular structure itself ; this is then 
found reddened and injected, and the entire gland appears to have 
become hypertrophied into a uniform, carnified, tough mass. The 
exudation may now either be absorbed again, when the gland will 
return to its former normal size and consistence, or the exudation 
deposited in the cellular tissue becomes solidified and organized, and 
leads either to a permanent increase in size, or to an absorption of 
the gland, when, as a result of compression, the proper glandular 
structure gradually atrophies and becomes obliterated. 

Therapeutics. — The treatment of parotitis is that of adenitis in 
general. As long as general febrile symptoms are present, rest, 
strict diet, and acidulous drinks are indicated. The swelling itself 
is most conveniently treated with inunctions of oil. Cold does not 
in the least accelerate the resolution of the swelling. Cataplasms 
and bran-bags are inconvenient and annoying, cause congestion 
of the head, and are not willingly tolerated, especially by small 
childi-en. If the parotitis is attended by very severe pain, and 
extensive, tense swelling, a few leeches will be found useful. Great 
restlessness is soothed by a solution of morphine (gr. \ to water 
I iij), a teaspoonf ul of which may be given every hour till its effects 
become apparent. Subsequent indurations must be treated by inunc- 
tions of mercurial ointment. The use of cod-liver oil for several 
months may prove of great benefit, as most children affected with 
this disease are scrofulous. 

(Z>.) Secondary parotitis is a very rare disease, and arises from 
protracted affections of the deeper structures of the mouth. The 
principal causes of secondary parotitis are mercurial salivation, diph- 
theria, or a neglected storaacace. It never attains the size, extent, 
and hardness of the epidemic parotitis, the face is not disfigured to 
such a degree, and the lobe of the ear is never pushed so far upward. 
The symptoms are limited to a slight swelling, and to pain upon 



MIASMATIC DISEASES. 529 

pressure from without, and on mastication. The lymphatic glands 
lying around and upon the parotid, and which, in affections of the 
mouth, swell up earlier and oftener than the parotid gland, render 
the diagnosis materially difficult. The best diagnostic cardinal points 
will always be the position of the lobe of the ear and the course of 
the disease. Thus the tumefied parotid undergoes resolution sooner 
and more regularly than the cervical lymphatics, which often become 
indurated, or degenerate into suppuration. In rarer instances, it 
may also terminate in suppuration, whereby severe general phe- 
nomena, a tardy increase in the size of the gland, and, finally, fluctu- 
ation and pointing, will take place. After a profuse and exhausting 
discharge, the process terminates in complete atrophy of the suppu- 
rating gland. As secondary parotitis is usually confined to one side, 
and as the mouth is thereby very severely affected, nothing definite 
can therefore be stated regarding the character of the salivai-y secre- 
tion of the diseased gland. 

The treatment is principally to be directed to the disease of the 
mouth, for which kali chloricum must again be mentioned as the 
sovereign remedy. The remainder of the treatment of the affection 
of the mouth will be found already described in the corresponding 
chapter. 

(c.) 3Ietastatic jycirotitis occurs in the course of typhus or scarlet 
fever, of variola, of measles, and generally in the first few days, at 
the climax of the disease, in which case death almost invariably fol- 
lows, or with the ushering in of convalescence, and then a far more 
favorable prognosis may be given. The etiological connection of 
parotitis with these exanthema is very uncertain. Among other 
causes, especially for typhus fever, a mechanical occlusion of the 
ductus Stenonianus, as a result of the dryness of the mouth, must, 
at any rate, hold good. In the cadaver, the parotid and its contig- 
uous parts ai'e found swollen, and the gland itself dotted with a 
number of small abscesses, the contents of which are either yellow 
thick pus, or brown sero-sanguinolent ichor. In grave putrid fevers, 
a general gangrenous sloughing rapidly ensues, by which the entire 
gland and its adjacent textures degenerate into an ichorous, brown- 
ish-green, fetid, decomposed mass. 

The symptoms vary in accordance with the degree of the general 
affection. If the typhus fever or the acute exanthemata has reached 
an intense degree, the patients will be totally unaware of the exist- 
ence of the complication ; if, on the other hand, it comes on during 
convalescence, they will present the same subjective phenomena as 
in the idiopathic, epidemic form. In general, it may be stated that 
metastatic parotitis runs a slower course, and much more frequently 



530 DISEASES OF CHILDREN". 

degenerates into suppuration, than the secondary, and still more than 
the idiopathic. Here the transition into suppuration takes place 
very often. The objective signs, size, extent, and hardness of the 
tumor, are of the same character as in the epidemic parotitis. Al- 
though, in the other forms, the question whether, in reality, the 
glandular parenchyma, and not the connective tissue surrounding 
the entire gland, and existing between the acini, is affected, must 
still remain undecided, nevertheless, in this metastatic parotitis, a 
parenchymatous disease may be assumed with certainty, by reason 
of the frequent and numerous abscesses found. 

The treatment, in the gravity of the complication, plays a subor- 
dinate part. Warm bran-bags, if the patients will tolerate them, 
seem to have a favorable influence upon the resolution of the swell- 
ing, and mitigate the pain. Incisions can only be made advanta- 
geously when distinct fluctuation is felt. If no pus is evacuated 
by a deep incision, consequently no abscess having been opened, no 
amelioration whatever will ensue ; on the contrary, still greater 
oedema and troubles result from this traumatic parotitis. If the 
process has made its appearance during a convalescence, it will be 
protracted uncommonly long, and life will have to be sustained by a 
tonic and stimulating treatment, with wine, eggs, meat, quinia, etc. 



SECTIOX III. MALARIAL DISEASES. 

K.— INTERMITTENT FEVER. 

IxTERiiiTTEXT Fever [FebHs Intermittens). — Intermittent fever 
occurs just as often in young children as in adults. Cases are even 
recorded of infants being born with enlarged spleens, and suffering 
febrile paroxysms at the same hour in which the mothers had their 
paroxysms during pregnancy. I have never met such a case ; the 
youngest child that I have had to treat for intermittent fever was 
eight weeks old. The symptoms presently to be described have 
reference only to children under two years ; in older children the 
whole course is so characteristic, that every one who has once seen 
an adult suffering from a paroxysm of intermittent fever will im- 
mediately recognize it. 

The etiology of infantile intermittent is naturally the same at 
all ages. The fever is confined to certain locations, and is never 
observed in children who have not lived, or at least stopped for some 
time, in malarial regions. The most exhaustive treatise on the eti- 
ology of malarial affections is to be found in Griesinger's " Infect- 



MALARIAL DISEASES. 531 

ing Diseases " ( Virchoio''s " Hand-book of Special Pathology "), in 
which the circumstances of the quantity of the water, condition of the 
earth, of the temperature, of the climate, etc., are discussed in detail.' 

Symptoms. — In children, the quotidian type is the most fre- 
quent ; still the tertian, and even the quartan, also occur. The 
hour in which the attack comes on is not always the same ; the 
paroxysm, however, is always confined to a certain period of the 
day ; the morning, afternoon, or evening. As regards the attack 
itself, it is usually not fully developed, but rudimentary in one or 
more of its phenomena. Actual chills, it is true, occur, in which 
the children are seized with shivering, low moaning, collapse, and 
have blue lips and nails ; immediately after they become decidedly 
hot, have a dry skin, great thirst, and restlessness, and finally break 
out in a general perspiration, thus completing a perfect picture of 
an intermittent febrile paroxysm. As a rule, however, the symp- 
toms are not so conspicuous, and often leave the malarial character 
to be divined by their recurrence every day, or every other day, at 
the same hour. The shivering chills are often totally absent, and a 
remarkable paleness of the skin, blueness of the nails and lips, dis- 
coloration around the eyes, cold extremities, and low whimperings, 
or slight convulsive twitchings of the facial muscles, are only pres- 
ent. The pulse does not become very much accelerated, but very 
small. Respiration is normal, as to frequency ; the breath does not 
become cool, nor does the temperature of the mouth sink in the 
least. During the various symptoms, representing the cold stage, 
children rarely pass any urine ; but, if they have partaken of much 
milk shortly before, they generally throw it up. This stage never 
lasts longer than one, or, at the most, one and a half hours. During 
it the child presents a most critical appearance, and the physician 
may seriously compromise his professional rejDutation if he should 
give a prognosis immediately on first beholding the child. I my- 
self once committed such an error in the early course of my pro- 
fessional career. 

In the second stage the vessels of the skin become turgid, the 
face is flushed, the pulse harder and quicker than in the cold stage, 
the cardiac impulse stronger, and felt over a larger area. There is 
very great restlessness, the child cries aloud, and is frequently at- 
tacked by convulsions, conjointly with which the pupils become 
remarkably dilated. The urine and stools ai*e retained. 

This condition may last from two to three hours, and is much 
more correctly observed and described by the mothers than the cold 
stage. But it is also often transient, lasting barely one-quarter of 
an hour. It is followed by a slight perspiration, the third stage. 



532 DISEASES OF CHILDREN, 

"While the patients are awake the perspiration is not very well 
marked ; the skin, it is true, feels moist, but drops of sweat are very 
seldom seen upon it ; free perspiration takes place only when sleep 
ensues. The heat and redness of the face then diminish, the thirst 
decreases, and the urine is discharged tolerably dai'k in color. The 
pulse assumes again its normal condition, and the patients once 
more present all the signs of general good health. But, in the 
intervals of freedom from fever, they are seldom perfectly well ; 
are generally very restless, have less appetite, and a sluggish, irregu- 
lar digestion. The febrile paroxysms are frequently so little pro- 
nounced that an observation of several days is necessary in order to 
confirm the diagnosis. 

The intermittent-fever cachexia, in small children, soon devel- 
ops itself, frequently in from one to two weeks, and is character- 
ized by the following symptoms : 

Anaemia appears very rapidly, the color of the skin becomes per- 
fectly white, or turns to a slight grayish tint, the lips and mucous 
membrane become pale, the emaciation progresses and becomes 
marked, slight cedematous swellings form under the eyes, the en- 
larged spleen is easily felt, and, when the emaciation increases, may 
even be seen. The liver also swells up, and its parenchyma becomes 
indurated (lardaceous liver). The intestines are tympanitic with 
gas, the stools are mostly diarrhceal, and, in the last days of life, 
sometimes mixed with blood. The important discovery of the 
presence of brown or black granular pigment-matter in the blood of 
intermittent-fever patients is an attainment of pathological micros- 
copy for which we are indebted to Virchow and Meckel (Melanse- 
mia) This pigment is seldom found in the blood of children, be- 
cause, for this purpose, it is necessary that the cachexia should be 
much prolonged, which, in children, is generally not the case, as 
they die of the disease too early. Moreover, intermittent fever is 
so easily recognized, and its treatment so rapid and effective, that, 
wherever physicians are consulted for it, it seldom advances to the 
development of the cachexia. 

Pathological Anatomy. — In this country, a child rarely dies dur- 
ing the attack, but, in regions where pernicious fever prevails, death 
may occur even from the first paroxysm. The anatomo-pathological 
condition is then purely negative ; a slight swelling of the spleen, 
with a superabundant amount of blood in the whole venous system, 
are the only abnormities. But, in the bodies of infants who have 
perished from the cachexia of intermittent fever, various morbid 
changes are met with, such as anasarca and effusions into the serous 
cavities, lardaceous liver, large lardaceous spleen, with brown or 



MALARIAL DISEASES. 533 

black pigment-matter most profusely accumulated in the spleen, in 
the liver, in the brain, upon the mucous membrane, and in the kid- 
neys, which are also frequently affected with Bright's disease. In 
such cases the urine found in the bladder is always albuminous, and 
casts may be seen in its sediment with the microscope. 

Treatment. — The attack itself, in our milder forms of intermit- 
tent fever, requires a not very energetic but an expectant treatment. 
For the cold stage, a high temperature and mild cutaneous irritants 
are sufficient, such as friction with a woollen rag, with spirits of 
camphor, or other excitants ; cool coverings, cold affusions to the 
head, the administration of plenty of cold water, and, when con- 
vulsions occur, one or two drops of laudanum, answer for the hot 
stage. The sweating that ensues should be encouraged in every 
manner possible. During the apyrexia the children must be kept 
upon a very strict diet, and in a uniform temperature. In sulphate 
of quinia, however, we have a very efficacious remedy for the pre- 
vention of the recurrence of the paroxysms. In children under one 
year, one grain, given in one dose, is generally sufficient to arrest 
the attack. To older children, two to three grains are given. The 
addition of sugar to this dose, thereby increasing its' bulk, with the 
view of improving its taste, is practically useless, if not disadvan- 
tageous, for the taste is not improved in the least. In young chil- 
dren it is almost always easy to administer this remedy. But older 
children, who are not trained to swallow powders wrapped in wafers, 
are often, notwithstanding their best intentions, unable to swallow 
them, or refuse to attempt it. In these cases, the employment of 
the remedy in the form of clysters may be practised ; the method 
is very efficient. 

A countryman, from a peat-moor, once brought his boy, five 
years old, to me, stating that he had suffered daily for six weeks 
from the fever, which the physician of his place was unable to cure, 
because it was totally impossible to administer quinine to the child. 
The boy was very anaemic, had a very large spleen, an indurated 
liver, marked ascites, traces of albumen in the urine, and slight 
oedema of the lower eyelids. I ordered him a ten-grain solution of 
quinine in one and a half ounces of water, and caused it to be ad- 
ministered in a clyster, in my presence, to which the child readily 
submitted. The man took him home to his moor again, and, al- 
though continually exposed to the malarial air, he had no further 
attacks, but, under a tonic treatment with 1^. mart, pomat., meat 
diet, and beer, completely regained his former health and spirits. 

When one dose of quinine is not sufficient, another must be ad- 
ministered during the next interval. The determination of the 
hour of administration, upon which great stress is laid by many 
35 



53i DISEASES OF CHILDREN. 

physicians, seems to be less important in children than in adults. 
The main point is always for the quinine to be well and thoroughly 
absorbed, and therefore it is advisable not to give it directly before 
or after a meal, nor immediately before the appearance of the chill, 
because during it the digestion is interrupted. 

In our intermittent fever, quinine has never yet failed in my 
hands to perform its duty, and for that reason I have never had 
occasion to resort to arsenic in the treatment of this disease. Still 
I would not hesitate for a moment, in case of failure, to use it, since 
Fowler's solution is very well tolerated by children. If the ca- 
chexia is ah-eady developed, an after-treatment will be necessary. 
The best remedy is the removal of the child from the malarial re- 
gion to a dry, elevated residence. Where this is not practicable, 
we have to limit ourselves to iron and a meat diet, combined, in 
older children, with small quantities of beer. 



CHAPTER YIII. 

LOCAL DISEASES OF THE SKIN. 

(1.) Erythema. Neonatorum. — Besides the physiological red 
discoloration of the skin, with which all normal children come into 
the world, and which, after a few days, becomes yellowish red, 
and finally bright red, an erythema papulosum also very frequently 
occurs in new-born children. 

Symptoms. — The erythema is usually most strongly developed 
upon the breast and back, and consists of small, dark-red pimples 
resting upon an equally red base. The cutis is but slightly infil- 
trated ; itching of the skin seems to be present, for the patients 
are uneasy so long as the exanthema is visible. On pressure by the 
finger the redness quickly disappears, but returns again in an in- 
creased degree as soon as it is removed. The erythema fades in a 
few days, and the darkest spots desquamate in very thin scales. 

There is nothing typical whatever to be observed in its whole 
course, and the entire process is sometimes completed in two, some- 
times again in fourteen days. The child may also be attacked by it 
more than once. Scarcely any general symptoms are occasioned by 
it, the children have no fever, the mucous membranes do not partici- 
pate in this affection, and the appetite is not disturbed, which fact 
alone sufficiently distinguishes this erythema from scarlatina and 
rubeola. The exanthema itself, certainly, has the greatest resem- 
blance to scarlatina, and, but for the accompanying symptoms, might 



LOCAL . DISEASES OF THE SKIN. 535 

be mistaken for the latter. It is a fact worth remembering, that 
new-born children are but little predisposed to take scarlatina. 

Etiology. — The causes of this erythema, most probably, are ex- 
ternal, from the circumstances that these children are attacked by 
it in the first few days of life, and from its repeated occurrence in 
one individual. Indeed, the delicate skin does not tolerate, from 
the very first, the irritation of the garments and baths, and is there- 
by excited into a high degree of hyperaemia, which constitutes ery- 
thema papulosum. 

Treatmeat. — Since erythema expires spontaneously in a short 
time, its treatment may be simply expectant. The skin should not be 
rubbed nor irritated so long as the erythema exists, especially after 
the baths, which need not be omitted even for one day. The patients, 
however, should be simply wrapped up in dry cloths, and all rubbing 
avoided. Mild infrictions of oleum coccos or some other pure oil 
seem to be soothing to these children. During this period their 
underclothes and diapers should be as fine and as soft as possible. 

(2.) IisTTERTRiGO (Chafing). — By intertrigo is understood a de- 
struction of the epidermis covering the opposing surfaces of a 
cutaneous fold, resulting from the rubbing of the two surfaces 
against each other. It is seen most frequently between the nates, 
in the groins, the armpits, and on the neck. Corpulent children, 
moreover, may become chafed on all the cutaneous folds of the 
body, though otherwise possessing excellent health, and having the 
best attention ; in lean children this only happens when the diapers, 
soaked in diarrhoeal excretions and urine, are allowed to remain in 
contact with the skin for some time. 

Redness and moisture of the affected integumentary folds form 
the first degree of intertrigo. The epidermis next softens, and may 
be wiped off as a white mucus, when the cutis will be seen totally 
exposed, dark-red in color, and painful to the touch. The secretion, 
that now becomes considerable, may increase in amount sufficiently 
to form crusts. With cleanliness, and proper treatment, the loss of 
epidermis is soon repaired ; but where the subjects are cachectic or 
atrophic, and if the primary cause, the diarrhoja, continues, the 
erosions will assume an ulcerative form, become coated with diph- 
theritic membranes, and in the worst cases even gangrenous. 

The ordinary intertrigo of corpulent children, under an appro- 
priate treatment, disappears in two or three days ; that occurring in 
atrophic children never heals so long as the diarrhoea lasts. 

Treatment. — As a prophylactic in corpulent children, semen li/co- 
poclii is very advantageously dusted in the cutaneous folds ; it pre- 
vents the rubbing and contact of the surfaces, and by its feeble hygro- 
scopic properties preserves them dry for some time. Usually, it is 



536 DISEASES OF CHILDREN. 

also emplojed by the laity as a remedy iu cases where the epidermis 
has already been lost, but here it is altogether out of place. The 
secreted exudation combines with the lycopodiuin, forms hard, large 
crusts, and considerably increases the inflammation of the skin. 
Where this injudicious measure has been employed, the crusts are first 
to be soaked oif with oil, and carefully removed. The existing excoria- 
tions are best treated with lead or zinc ointment, and, among the 
poor, ordinary tallow may be substituted for these remedies. Tepid 
baths are the best preventive against chafing. 

(3.) FuRUNCULOSis. — Children of various ages frequently sufifer 
from solitary furuncles or boils, which, corresponding with the more 
rapid metamorphosis of the tissues generally, comparatively quickly 
cast off their core and soon heal up. But, in children the progeny of 
tuberculous parents, the case is totally different. 

In the latter, large numbers of furuncles occasionally occur on the 
occiput and over the entire head, come on one after the other, break, 
and cause the child great suffering for a long time. Usually no firm 
core is expelled, as in the simple phlegmons, the contents consisting 
only of thick, yellowish, or bloody pus, which often becomes aggluti- 
nated with the surrounding hairs into thick flat crusts. 

Coincident swelhng of the glands of the nape of the neck occurs ; 
they are very painful to the touch, and, in fact, now and then suppu- 
rate. 

These furuncles may become so numerous that the whole occiput 
is finally covered with a mass of confluent crusts, under which new 
ones constantly appear, elevate tlie old crusts, and, by the discharge 
of their contents, assist in thickening it. In this manner the extreme- 
ly painful process is protracted for many weeks. Yoimg children 
scarcely sleep at all ; older ones are only able to sleep when the 
nurse takes them upon her arms, where they can then lay their 
faces upon her shoulder. Finally, the crusts dry up, and no acces- 
sions follow. The scabs become loose and may be removed, to- 
gether with the hair, or what there is left of it. The marks of the 
phlegmon may be recognized for some time after by the bluish- 
red, glistening cicatrices. The consecutive swelling of the cervical 
glands also disappears. The nutrition and development of the chil- 
dren, from the constant sleeplessness, suffer in an extreme degree ; 
but, if the digestive organs are not attacked by catarrh, they will 
improve rapidly after the furunculosis has been cured. In perfect- 
ly healthy children this disease is scarcely ever observed ; but ordi- 
narily it is the harbinger of a long list of scrofulous affections. 

Treatment. — This affection cannot be cut short. The only thing 
the physician can do is to relieve the constant restlessness and 



LOCAL DISEASES OF THE SKIN. 537 

sleeplessness, and thus render a great service to the patients and 
their relatives. This is very easily accomplished by giving one or 
two drops of laudanum, by which a few houi's of refreshing sleep 
are induced, even in the most restless children. No bad effects 
are ever seen from this moderate use of opium. 

Locally, the crusts are best treated with some oleaginous sub- 
stance. Simple cerate, or some mild ointment, is applied daily until 
the crusts soften and fall off. By these measures, the painful pull- 
ing of the aa^glutinated hairs is avoided. No relief is obtained from 
prematurely opening the boils, and it is best, therefore, to wait un- 
til they are sufficiently large, and the apices have become yellowish, 
when they may be punctured with a needle. By this means the 
painful tension and several hours of pain may be avoided. 

(4.) Scabies — Itch. — Since, in the composition of this chapter, a 
knowledge of the diseases of the skin in general is presupposed, I 
may appropriately omit a zoological description of the itch animal- 
cule, and immediately proceed to speak of the morbid alterations of 
the skin produced by it in small children. The best description and 
representation of the acarus scabiei are to be found in Simon'' s Dis- 
eases of the Skin, and Kuchemneister^ s Parasites. 

Symptoms. — The acarus scabiei penetrates, with especial prefer- 
ence and remarkable rapidity, the delicate epidermis of the nursling, 
and, a few days after the infection has taken place, the consecutive 
exanthema begins to appear. In young children this varies accord- 
ing to their age. Very young infants, a few weeks old only, have 
it in a less degree, because they are still unable to scratch themselves 
so severely, while those a few months old become entirely covered 
with it. 

Generally, the exanthema is most markedly developed upon the 
hands, buttocks, and abdomen, and in the beginning presents the 
following form : A rose-colored papule originates upon various 
parts of the body, and upon their apices small transparent vesicles 
become develo^Ded, accompanied by intense itching. When these 
vesicles remain uninjured, their contents in a few days will become 
opaque and purulent, thus forming pustules which burst spontane- 
ously, and these leave behind them a yellow circular crust. But, if 
the vesicles are prematurely scratched open, as is usually the case, 
then these irritated spots will bleed a little, and the small crusts 
that then form are of a black color. 

The more the children scratch, the more extensive will become 
the exanthemata. By the coalescence of single pustules, large ulcers 
often form, especially on the lower extremities and on the buttocks. 
These ulcers resist the treatment for a long time, and in chronic 



53S DISEASES OF CHILDREN. 

cases, the Avhole skin, even those parts of it that are fi'ee from pus- 
tules, assume a dry, scabby character. 

The state of the general system of small children is much af- 
fected, in consequence of the incessant itching and sleepless nights, 
and they often become markedly emaciated if the scabies is not 
properly treated, which is, unfortunately, often the case even at 
this day. 

As regards age, new-born children are the only ones exempt 
from it, for the reason that the animalcule requires several days to 
penetrate the epidermis, and to produce the exanthemata. Not until 
this has taken place do we become aware of the course of the ani- 
malcule, for, previous to that, there is, in most instances, no cause 
for examining the integument with great attention. Infants a few 
weeks old are very susceptible to the itch, and generally acquire it 
if any child has introduced it into the house. 

Scabies is more difficult to diagnosticate in children than in 
adults, because the animalcule has not, as in the latter, a prefer- 
ence for the hands, but burrows its passages (or cuniculus) at any 
point in the body. As only a single one is generally found at a time, 
it is often necessary to search for a long time before a characteristic 
cuniculus can be discovered. The discovery of these cuniculi is 
rendered still more difficult by their remaining perfectly white, and 
differing but slightly from the normal skin, while those on the hands 
of adults soon become dirty blackish in consequence of the different 
location, and cannot be made white by simple washing, the dirt that 
has found its way beneath the epidermis remaining entirely unaf- 
fected by the water. In young children these tracks are most fre- 
quently found upon the skin of the abdomen and buttocks, also on 
the face, a condition which is never observed in adults. The at- 
tendant exanthemata is always more extensive and severe in the 
foi'mer than in the latter. 

Older children, with a fine, delicate skin, sometimes have exces- 
sively large pustules, which may reach to the size of a split pea, or 
larger. When these are punctured, a large drop of pus escapes, 
and, generally, the pustules fill again several times if their contents 
are evacuated by repeated punctures. Most of them leave a dark- 
colored cicatrix, which is visible for a long time. This large pus- 
tular eruption has also been called fat scabies (fette Kriitze). 

The course of scabies in children is always very tedious, and 
may be prolonged for months if proper ti'eatment be not adopted. 
In addition to that, the pustules and excoriations constantly become 
larger and more numerous, the restlessness still greater, and the 
emaciation makes alarming progress. Finally, when almost the en- 



LOCAL DISEASES OF THE SKIN. 539 

tire skin is covered with thick scabs, a spontaneous improvement 
seems to ensue even without any treatment. 

Therapeutics. — The treatment of scabies in children is essentially- 
different from that proper in the adult, and varies according as to 
whether the consecutive eruption consists only of papules, or also 
of pustules and ulcers. In infants who are still unable to scratch 
themselves, it is usually only papixlous, and, in such cases, the rapid- 
cure may very advantageously be employed. 

The sovereign remedy for the cure of scabies, and which has 
cast all others in the shade, is balsam of Peru. The entire body of 
the child is to be smeared with the balsam in the evening, and 
bathed in the morning with soap and water. A single infriction 
generally suffices to kill the acari, but, to make it perfectly sure, 
the remedy should be used two or three evenings in succession. This 
treatment with Peruvian balsam has the advantage over other 
methods in being entirely non-irritating, and hence does not inter- 
fere with the cure of the secondary exanthema. The only objection 
to its use is that the clothes become badly stained, and, notwith- 
standing repeated washings, remain discolored for a long time ; 
hence the necessity of using old and worn-out articles. 

In children under five years of age I use this remedy only ; in 
older children, who have only a few pustules, the usual solution, 
solutio Vlemingx (a lotion of sulphur and lime) may be used like 
the balsam. With these two remedies, thus applied, any case of 
scabies can be cured in from three to four days. 

That no favorable result will be attained in families, where several 
members suffer from scabies, unless all of them are simultaneously 
subjected to the treatment, is of itself understood. In the lower 
classes of the people, where a sufficient change of linen cannot be 
commanded, and the procuring of the baths is too expensive, the 
chances of a speedy recovery are very small, and the little patients 
will not get better until the older members have undergone a thor- 
ough treatment in some hospital. 

(5.) Congenital N^vi — Mother's Makks. — As na3vus vascu- 
losus, varix, telangectasis, have already been treated of in connec- 
tion with the diseases of the vessels (page 210), it only remains for 
us to describe here the congenital pigmentary nsevi, moles, and con- 
genital adipose tumors. 

By pigmentary na3vi, stigmata, spili, spots on the skin are un- 
derstood, which are round or irregular in form, yellow, brown, black, 
or gray in color, and vary in size from a pea up to the palm of the 
hand, and, in some instances, cover even a large part of the body, 
the whole back, or an entii'e extremity. The alteration of color is 



540 DISEASES OF CHILDREN. 

due to a deposit of pigment in the Malpighian net- work. On these 
places the skin is sometimes hypertrophied and uneven, so that the 
mole projects somewhat above the sound skin, and occasionally is 
profusely studded with hairs, by which it is made to resemble the 
brown fur of an animal. The pigmentation is not always distributed 
alike over the whole ntevus ; sometimes the centre, sometimes again 
the periphery is brighter. These pigmentary moles never become 
enlarged, except in proportion to the growth of the body in general, 
and occasionally they remain exactly of the same size as at first. 

By warts are understood higher prominences of the skin, pro- 
duced by an elongation of the papillae, and the formation of new 
tissues ; these are usually of a brown color. As Simon first pointed 
them out, they are often unilateral, and thus resemble herpes zoster 
in their mode of dissemination. These neuropathic cutis-papilloma, 
to which Isidore Neumann has lately called attention, are quite 
rare. I have seen but two cases in my practice of twenty-five years' 
duration, which, after a few months, got well spontaneously. Those 
warts that so frequently originate later in older children differ essen- 
tially from these under consideration. The former consist of a 
number of perpendicular prominences of the elongated papillae of 
the skin, which are covered by an indurated layer of epidermis. 
They are not pigmented, develop themselves on the different parts 
of the hands and face, and after several months disappear, without 
leaving any traces behind, and for this reason have become such 
desirable objects of attention for the so-called sympathy-cure, stu- 
pidity, and imposition. The congenital warts, first described, never 
disappear spontaneously. 

By nmvi lipomatodes, adipose tumors, we understand roundish 
or cylindrical fatty growths, covered with normal skin, most of 
which are pediculated, but sometimes seated upon a broad base. 
Strictly speaking, they do not belong to the diseases of the cutis, 
for the skin is entirely unaffected, but they are due to an abnormal 
extuberation of the subcutaneous adipose tissue. These usually 
enlarge in proportion to the growth of the body, but in some cases 
also faster. 

Therapeutics. — In regard to the total or partial extirpation of 
these various moles, and the cautions that are to be taken into con- 
sideration in the operation, according to their situation, we refer 
the student to the standard works on surgery. In small nrevi, sur- 
gical procedures may frequently be avoided by performing vaccina- 
tion upon them. The punctures, with the vaccinating needle in 
these cases, must be made so close to each other that the pustules 
resulting therefrom will coalesce. 



LOCAL DISEASES OF THE SKIN. 541 

By the seventh or eighth day the whole nEevus rises up as a 
high, jjainful pustule, which suppurates for a long time, and fre- 
quently ulcerates ; ultimately, however, heals, and leaves a rose- 
colored or white eschar. Although, in large moles, this process is 
not capable of destroying all the pigment, still it serves to divide 
them into small islands, which, by subsequent operations, may be 
removed with greater ease. 

In children who are already vaccinated, deep pustular ulcera- 
tions may be produced by a continuous local use of tartar, stibiat., 
or corrosive sublimate, in the form of a paste or ointment ; and, by 
the time these pustules heal, the whole mole will be found destroyed. 
At least, the hair-follicles, in those moles that are covered with 
hairs, are destroyed by this means, and their disfiguring appearance 
is thereby considerably diminished. 

[Electrolysis has been successfully resorted to for the cure of 
these warts.] 

In the sim23le, non-congenital warts of older children, which 
start up in a crop in various places at the same time, all surgical 
measures, cutting, and cauterizing, are totally unnecessary, for 
they disappear spontaneously in the same manner they appeared. 
The internal use of small doses of alkaline carbonates, or of carbon- 
ate of magnesia, is said to accelerate the disappearance of these warts. 

(6.) BuEXS ( Comhiistio). — Burns very often occur in children, in 
consequence of their ignorance and carelessness ; but, when a child 
has once burnt itself severely, there is little danger of the repetition 
of the accident. This fact has become proverbial, that '' a burnt 
child dreads the fire." Most frequently the children burn them- 
selves about the upper extremities and face, ordinarily on hot uten- 
sils, or with hot liquids, milk, water, or soup. The severer grades 
of burns, characterized by total or extensive destructions, with the 
formation of scabs, are for this reason rare. We seldom see any- 
thing more than the formation of blisters. 

Suppuration, however, is also severe and protracted even after 
this inferior grade of burns, and the cicatrices are very much dis- 
posed to become contracted. In extensive burns, a severe reaction 
and violent fever come on as early as the second day, and in nerv- 
ous children these will be accompanied by convulsions. Usually 
the general symptoms are not very violent, and, under proper 
treatment and position of the burnt part, disappear after a few 
days. 

Treatment. — The local treatment is conducted according to the 
degree of the burn. The pains of simple erythematous bums are 
most quickly allayed by inunctions of lard, and covering the part 



542 DISEASES OF CHILDREN. 

with cotton-wool. Cold is advisable only in very small erythema- 
tous burns ; in extensive burns, on the contrary, the most expe- 
rienced surgeons, such as Walther, JSTusshaum, and others, consider 
it dangerous. 

Large blisters should be punctured with a fine needle, and the 
serum allowed to escape ; the epidermis, however, should not be 
removed, for it assists the process of cicatrization better than any 
kind of plaster. The best results in these cases are derived from 
pencilling the part with a concentrated solution of nitrate of silver 
( 3 ss to water 3 ss). But this remedy causes too intense pain 
where the cutis is denuded. When suppuration has set in, simple 
cerate and subsequently lead-and-zinc ointment may be used. Any 
two opposite surfaces when denuded of their epithelium, for ex- 
ample, between the fingers and toes, should not be allowed to 
remain in contact with each other, but should be carefully kept 
apart by interposing pieces of adhesive plaster or lint smeared with 
cerate. 

The diarrhoea which sometimes comes on in extensive burns 
should be controlled by opium. The treatment of the general symp- 
toms should be antiphlogistic. For the continuous restlessness and 
sleeplessness, opium is, once more, the sovereign remedy. 

In deep burns of the hands and arms, marked contractions of the 
tendons result from the cicatrizations, and an effort should there- 
fore be made, by the aid of counter-extending apparatus, to prevent 
them. 

(7.) CoxGELATio, Feost-bite, Chilblain". — So long as chil- 
dren are unable to walk, freezing of the extremities does not read- 
ily occur. But, if they are exposed for a long time at this tender 
age to a low temperature, general cyanosis comes on, and they 
very quickly fall asleep, to wake no more. Indeed, this criminal 
practice is probably performed oftener than the authorities become 
aware ; for it is scarcely possible to prove it by a post-mortem ex- 
amination. 

In winter, chilblains are of very frequent occurrence in older 
children who play a great deal in the snow, and have little respect 
for cold and wet feet. Here, as in burns, three degrees are dis- 
tinguished. First grade : redness, slight swelling, itching, and 
pricking, especially in chilblain. Second grade : bloody blisters, 
which in part originate through the influence of cold, but in pari, 
also from pressure of the shoes, and therefore occur predominantly 
on the heel and toes. Third grade : gangrene of the skin or of 
entire extremities. The first two are the principal grades which 
occur in children. 



LOCAL DISEASES OF THE SKIN. 543 

Treatment. — Gelatio of the first degree, when still fresh, is best 
treated by rubbing it for a little while with snow. If it has already- 
existed for some time, it is no longer possible to remove it quickly, 
and the evil, as a rule, is too slight to make it necessary to subject the 
children on that account to a treatment of several weeks' duration. 
Chilblains usually disappear spontaneously as the spring of the year 
sets In. The greatest benefit has been derived from pencilling the 
parts mth a solution of nitrate of silver or iodine, especially where 
the itching is intolerable. Various kinds of fat and ointments, equal 
parts of tallow and brandy, etc., and particularly cabinet-maker's glue, 
from which some very striking effects may sometimes be seen, are 
some of the most popular remedies. 

The active discolored ulcers which originate from the bloody blis- 
ters of the second grade, resist the treatment for a long time. It is 
frequently necessary to cauterize them, and to treat them with diges- 
tive ointments until healthy granulations appear on a level with the 
skin. All pressure, of course, must be avoided. 

These are the most important diseases of the skin which in form 
or treatment vary from those of the adult. All others, for example, 
favus, icthyosis, pityriasis, lichen, zoster, urticaria, peliosis, etc., are 
similar in character to those of the adult, and for this reason merit 
no further attention here. Some of the cachectic cutaneous afifec- 
tions will yet be specially treated of in the section on scrofula and 
syphilis. 

The original plan of this work was, that it should also contain a 
chapter devoted exclusively to the diseases of the organs of locomotion, 
of the bones and muscles. But on more accurate examination it was 
seen that the greater part of them require purely surgico-orthopedic 
relief, and the specialists who have written upon this subject have al- 
ready produced a very extensive literatxire. We would, therefore, have 
to be either very minute or content ourselves with merely furnishing a 
a simple extract from the writings of the later surgeons and numerous 
orthopedists, and for that reason prefer to refer the student at once to 
these authors. To this chapter would belong defect and malforma- 
tion of the hands and feet, talipes equinus, varus and valgus, curvatures 
of the spinal column, traumatic luxations, and fractures. 

The morbid alterations of the bones produced by scrofula and ra 
chitis will be described with the cachexiae. 



5i4- DISEASES OF CHILDREN. 

CHAPTER IX. 

GENERAL DISEASES OF THE SECRETIONS. 
CACHEXIA. 

(1.) Rachitis, Rickets, English Disease, Double Limbs. — By 
rickets is understood a developmental disease of the skeleton, in which 
a diminution of the calcareous constituents of the bones is the princi- 
pal symptom. The earliest definite descriptions of rickets date from 
the middle of the seventeenth century, and were given by the English 
physicians 'Whistler, Boot, and Glisson. About this time reports of 
a new disease were heard from various parts of England, and a com- 
mission, consisting of the physicians just named, was appointed to 
investigate it thoroughly. 

Since that time but little has been added to our knowledge of the 
pathology, or causes, or varieties, of rachitis, till some fifteen years ago 
Elsiisser discovered the rachitis of the skull. The pathological anatomy 
has been considerably enriched and elucidated since then by the re- 
searches of KoUiker, Virchoxc, and Hermann Meyer. 

Pathological Anatomy. — For the purpose of correctly comprehend- 
ing the rachitic alterations, it is necessary briefly to recapitulate the 
physiological growth of the bone. Every tubular bone grows in length 
and thickness. It grows in length by new layers of cartilage-cells 
which constantly form between the epiphyseal cartilage and the bone, 
in which calcareous salts are then deposited. It grows in thickness by 
the addition of new layers of bony substances immediately beneath 
the periosteum, from the tissue by which the latter is cemented to the 
bone. As the growth in thickness is much more insignificant, and 
progresses slower than that in length, the disturbances of the physio- 
logical growth at the cartilaginous ends are also more striking and 
liable to occur. 

While the bone is enlarging externally in every direction, by the 
addition of new elementary tissue, the medullary space witliin it also 
increases in circumference. Thus we have a constant new formation 
of bone externally, an absorption of bone internally. The femur of a 
child may with ease be put into the medullary canal of the same bone 
of an adult, so that, by the time the child has grown up, the original 
infantile bone has been completely reformed. 

The physiological growth of a bone consists, then, in — 

(1.) New structural cell-elements deposited on its upper surface. 

(2.) Their prompt ossification ; and in 

(3.) Absorption taking place in the centre of the bone. 



GENERAL DISEASES OF THE SECRETIONS. 545 

Rachitis consists in the suspension, or in the imperfect performance 
of the second function or process, while the first and third remain 
normal, by which various very striking and peculiar alterations in 
color, form, and consistence, become perceptible. 

In regard to color^ the rachitic bone is particularly distinguished 
by a dark-red color, which, on the skull, may even assume a bluish 
redness. The more livid the bone, the greater, as a rule, has been 
the duration and the degree of the rachitic disease. All the bones of 
the same skeleton are not always reddened in an equal degree, some 
are darker, others again are brighter in color, and from this alone it is 
readily seen that rachitis is no simple chemical process, but is due to 
a complicated anatomo-physiological condition. 

No rachitic bone retains its normal form. All the sharp angles of 
the bone become rounded off, the tubular bones in all cases become 
shortened, they cease to grow in length, the epiphyses swell and be- 
come bulbous, a condition which is most plainly seen on the sternal 
ends of the ribs, which are curved in various directions. On the 
tubular bones, for example, on the ribs, simple curvings occur, but 
very frequently actual fractures, or, more correctly speaking, contor- 
tions of the bones occur, especially in those of the lower extremities. 
In advanced rachitis the external layers of the bones, as we will show 
more in detail in the delineation of osseous derangements, contain so 
little calcareous salts, that they cannot be completely broken. 

The internal parts of the bone lying next to the medullary canal, 
formed before the appearance of the rickets, may, it is true, break, 
and do indeed very frequently break, owing to their attenuation, in 
consequence of the absorption that goes on within. The external 
portions of the bones, however, yield, and, though they bend, still do 
not break, and therefore no displacement of fractured ends can take 
place. The bones that are bent, after the manner of a quill or willow- 
twig, subsequently heal with a blunt angle. This bending of rachitic 
bones, and the subsequent angular deformity, may result from the 
action of the flexor muscles and from the superincumbent weight of 
the body. 

The apex of the angle thus formed in the forearm looks outward 
and forward, that of the arm almost straight outward, that of the 
thigh forward and outward, and that of the tibia, which usually bends 
near the ankle-joint, straight forward. 

When such an infraction is sawn through longitudinally, after 
complete recovery, compact substance will be found on the convex 
surface only, and on the concave a broad layer of spongy substance. 
The medullary canal is completely closed at the point of fracture, by 
thick bony extuberations, which subsequently become attenuated, 



546 DISEASES OF CHILDREN. 

though they never disappear entirely. "We shall speak more minutely 
of the alterations of form of the individual parts of the skeleton when 
we come to treat of symjDtomatology. 

The diminution of the consistence of rachitic bones is very remark- 
able. Incisions may be made several lines in dsptJi^ and, when the 
disease is much advanced, the bones may even be cut through en- 
tirely without any very great exertion, and without notching the 
knife. These are the coarser anatomo-pathological signs of a rachitic 
bone. 

When the affected skeleton is subjected to a closer examination, 
the following alterations, more or less marked on all the bones, will be 
found : the periosteum is thicker than usual, of a milky opacity in 
many places, and of a rose-red color. On attempting to pull it off, 
small and sometimes large fragments of bone will remain adherent to 
it ; the bone is always dark red, and has a particularly rough external 
surface. This state of the periosteum is most distinctly seen on the 
frontal bones in craniotabes. The skull, in this case, is sawn, or may 
even be cut through with the knife, with the greatest ease ; and on its 
posterior parts it is impossible to use the saw, for the spots, that have 
become attenuated to the thickness of a card, "wdll yield, become de- 
pressed, and irregularly torn by the saw. From the section through 
the frontal bones, small drops of bloody serum exude ; from the sec- 
tion of the temporal and parietal bones there will be less, and from 
that of the occipital there will not be the least of such serum. The 
frontal bones are always slightly thickened, sometimes to twice their 
normal thickness, and the anterior portions of the parietal bones in 
contact with the coronal suture partake in this thickening ; while the 
posterior portions, on the other hand, are quite as often attenuated 
as in the normal state. Toward the lambdoidal suture, both it and 
the occipital bone become membranous in spots, which are of a 
yellowish-red color. The other parts of the bone which are not en- 
tirely wasted become extremely thin, of a bright color, and totally 
devoid of diploe. By holding the cranium up toward the light, the 
extent as well as tlie degree of this rachitic thinning, the craniotabes, 
is clearly seen. 

If the calvarium is examined on its inner surface, numerous de- 
pressions are found, entirelj'' on the occipital portion, answering to the 
impressiones digitatce, each one of which corresponds to a cerebral 
convolution, whose pressure produced the attenuation of the bone, an 
atrophy indeed of the osseous substance. Finally, the dura mater 
and 2>&'>'ic'^cinium are in contact with each other, by which, in the 
dried preparation, the osseous tunics simply appear to be pierced and 
the membranes left intact. In these membranes, which resemble the 



GENERAL DISEASES OF THE SECRETIONS. 547 

dried fontanel, some white opaque points are still occasionally to be 
seen, which, on close examination, prove to be masses of unabsorbed 
calcareous mater. Elscisser, in his treatise on " The Soft Occiput," 
delineates a calvarium with nearly thirty apertures. Such a specimen, 
however, must be looked upon as one of the most extreme instances. 
The pericranium is, where it is stretched over the apertures, as well as 
in their vicinity, opaque and hypertrophied (PI. VI., Fig. 4). 

The pathological history of the soft occiput is: (1), one of de- 
ficient deposit of the usual phosphates in the external osseous layers 
of the entire bony skull ; and (3), of absorption of those portions of 
the bone which have been softened by the pressure of the weight of 
the brain. 

On the epiphyses of the tubular bones, additional characteristic 
signs may be observed. When a longitudinal incision of the articular 
head of a long bone — the femur, for example — ^is made, a thicker 
layer of cartilage is seen than in the normal condition (PI. VI., Figs. 
1-3 a), and the line between the bone and cartilage, instead of being 
straight, is very irregularly indented and undulating (PI. VI., Figs. 
1-3 b). The apices of the undulations which jut out from the bone 
into the cartilage are intensely injected, and contrast strongly with 
the bluish cartilage. The microscopical and chemical examination of 
the broad, bluish transition-layers, between the bone and cartilage, 
proves conclusively that it is a bone which has been retarded in its ossi- 
fication, in which no bone-corpuscles at all, and but few traces of cal- 
careous deposits in particular, are found. 

On the diaphysis of the tubular bones equally marked alterations 
take place. The periosteum is materially thickened, and cannot be 
pulled ofi" smoothly from the bone. Some fragments of porous bone 
are always torn off with it, and adhere to its inner surface. Imme- 
diately beneath the periosteum, broad whitish or reddish layers are 
found, which present a fine porous, pumice-stone-like structure. 

The trabecul£e of this mass, according to Virchoio, stand like per- 
pendicular radise upon the surfaces of the bone. Deeper still, these 
radiae are seen to be interrupted, first by a white and dense line of 
cortical layer, which is parallel with the upper surface of the bone. 
Then follows a new stratum of the same material, of a reddish color, and 
with stronger radice, which are again intersected by a compact parallel 
layer. Thus these layers alternate with each other a variable number 
of times, but the radi?e of the spongious layers constantly grow thicker, 
the nearer tliey approach the medullary canal, and their interstices 
become larger and redder, while the parallel layers become denser 
and firmer. 

The rachitic tubular bone is softest and most porous directly be- 



548 DISEASES OF CHILDREN. 

neath the periosteum, and constantly grows firmer toward the centre. 
The hj-pertropliy of the periosteum, and the softened condition of the 
external layers, explain also the singular process of infractions, and 
the impossibility of detecting actual displacement of the fragments 
and crepitation. These are the most important statements concern- 
ing the pathological anatomy of these bones. They are exhaustively 
and thoroughly depicted by Virchow in his Archives, vol. v. 

The chemical examination of rachitic bones has always shown a 
marked diminution of the phosphates and carbonates of Hme ; the cal- 
careous salts, instead of constituting two-thirds, often only forming 
one-fifth of the dried bone. In the urine, on the contrary, the phos- 
phates are found augmented from three to five fold. 

This increase of the phosphates in the urine, and its diminution in 
the bones, are not to be regarded as a process in which the calcareous 
salts already deposited in the bones are redissolved, and then ex- 
creted by the kidneys. The salts once deposited in the bones remain 
in them ; a small quantity only may, as a result of the absorption that 
occurs in the parts in the immediate vicinity of the medullary canal, 
again come into circulation. The new enlargements in the longitudi- 
nal and transverse diameter of the bones, however, do not receive any 
more calcareous salts, and the salts of lime introduced with nutriments 
find no consumption in the organism, but are immediately excreted by 
the urine. 

TFAy the deposit of calcareous salts in the bones ceases is still en- 
veloped in complete obscurity. It is certain, however, that it is not 
a simple chemical redissolving of the already-perfect bone by an acid, 
for otherwise its structures would, both on the periphery and in the 
centre, be alike deprived of calcareous salts, which is certainly far 
fi'om being the case. The layers immediately adjacent to the medul- 
lary canals are much more compact and richer in salts than those of 
the periphery. 

If the skeleton of a child who has recovered from rachitis be ex- 
amined, the bones will still be found cm-ved in various degrees, the 
skull large, its sinciput hypertrophied, and the individual bones are 
remarkably heavy. All the soft, spongy, bony masses that have 
formed during the rickets have become converted into dense, com- 
pact osseous structure, and this subsequent ossification exceeds in 
hardness even the normal bone, on account of which they have also 
been called sclerosis, and in extreme cases even eburneatio. 

No constant alterations are found in the rest of the organs, but the 
lungs, in all cases of marked rickets of the thorax, exhibit acquired 
atelectasis, and severe bronchitis, already spoken of in detail in the 
chapter on pulmonary afiections, page 250. The muscles are pale and 



GENERAL DISEASES OF THE SECRETIONS. 549 

flabby, and in various places, especially in the heart, reveal fatty de- 
generation. The liver often displays a decided augmentation of fat. 

Symptoms. — Rachitis is a tolerably acute affection, and generally 
appears on the head first, and always before the close of the first year 
of life. Next in frequency it is seen in the ribs, noticeable several 
weeks after commencing rachitis of the skull, and, lastly, in the lower 
extremities, the pelvis, and spinal column. 

Formerly an especial prodromatory stage was assumed, and to it 
disturbed digestion, acidity of the stomach, and defective condition 
of the excretions, with general malaise, were supposed to belong. On 
the other hand, however, it should be borne in mind that the com- 
mencing peiiod of rickets was entirely unknowoi before the discovery 
of rachitis of the skull by Elsasser in 1843, and that most of the signs 
of the so-called prodromatory stadium are now seen to be prolonged 
far into the disease itself. 

Rickets is a visible and comprehensible disease, and it is therefore 
necessary to investigate more minutely the alterations of the individ 
ual parts of the body which result from it during life. 

A.—BAGHITIS OF THE SKULL. 

Rachitis of the skull, with its peculiar phenomenon — softening of 
the occiput — was discovered by Elsdsser. It is worthy of remark that, 
previous to the publication of Elsdsser's work, no physician had any 
idea of this extensive morbid condition of the occiput, though it is one 
easy of examination and of detection. Neumann, for example, says 
that the bones of the head never soften through rachitis ; on the con- 
trary, they often grow at the expense of the other parts of the body. 
Miescher says that all the bones soften except those of the head. 
Various other remote alterations are indeed likely to originate about 
it, such as increased growth above the usual dimensions. Schnitzer 
and Wolff say that the bones of the skull never soften ; they even 
grow, apparently at the expense of all the other parts. 

The following are some of the alterations which occur about the 
rachitic skull : 

The anterior fontanel, which, in normal children, closes at the 
latest at the end of the second year, remains open three to four years, 
and may even remain cartilaginous up to the sixth year. The serrated 
suture, which otherwise we find closed by the end of the first year, is 
frequently still ununited in the third year. The coronal suture, in- 
stead of being united in four months, remains open at the end of two 
years, and the lambdoidal, instead of being closed at three, is still 
open at the end of fifteen months. Rufz has instituted accurate 
measurements of the skull, and found that the longitudinal and the 
3(3 



550 DISEASES OF CHILDREN. 

transverse measurements exhibit but slight deviations from the normal ; 
but the peculiar angular projection of the protuberances of the frontal 
and parietal bones robs the sinciput of its usual globular form, and 
gives it a quadrangular, clumsy shape {tete carree). 

After recovery from the disease, a depression usually forms along 
the course of the coronal suture, which gives to the sinciput, when 
seen from above, the form of a calabash, and is due to an hypertrophy 
of the frontal bones. Numerous depressions and elevations in general 
take place during rachitis, which opens a wide field of research for 
cranioscopy. 

The soft occiput is met with in children from the third month on, 
but is seldom seen in those who have passed the second year. No 
constant prodromata are observed. Many children may have, indeed, 
been previously subject to a bronchial or intestinal catarrh ; others, 
however, have enjoyed the best of health, and, up to the appearance of 
the craniotabes, were well nourished, fresh, and hale. 

The disease begins with profuse cejihalic perspiration, which often 
soaks through the pillow, and a nocturnal restlessness, increasing gra- 
datim, becomes noticeable at the same time. Children, who otherwise 
slept uninterruptedly for several hours, wake up every quarter of an 
hour crying, and rub and bore the head into the pillow. Changing 
the posture of the head quickly tranquillizes them, but only for a short 
time. The incessant rubbing of the head on the pillow produces a 
complete alopecia of the entire occiput. 

After some time the whining and discontentedness grow worse, 
extending even to the daytime, and attentive nursery-maids soon 
notice that the discomfort is subject to the varying positions of the 
head. The patients cry, and constantly bore the head when they are kept 
horizontally, or on the arms while being fed, or put to sleep, but soon 
become quiet when they are raised up and the occiput is relieved from 
all pressure. They then take their food vdih. the greatest comfort, and 
prefer also to lie with the face resting upon the nurse's shoulder, and 
the occiput entirely free. Older children occasionally quickly turn 
over in bed on the belly, and lie with the forehead pressed into the 
pillow. 

The feeble growth of the hair in general, and the alopecia of the 
occiput, are very noticeable, and, on closely inspecting the skull, the 
occiput is generally found flattened and the protuberances more angu- 
lar than usual. For the purpose of a more accurate manual examina- 
tion, the occiput should be taken upon both hands and felt of with the 
ends of the fingers. 

I examine the whole posterior region of the head, from the lamb- 
doidal angle to the mastoid process, twice carefully by the ends of the 



GENERAL DISEASES OF THE SECRETIONS. 551 

fingers. The first time, for the sake of precaution, I exercise only- 
slight pressure with the flat, extended fingers, so that, in case large, 
soft places exist, no violence may be done to the unprotected brain. 
The second time, I bend the fingers somewhat, and with the tip 
ends press forcibly upon every part of the occiput and parietal 
bones. By this procedure even the minutest point of attenuation 
marked by depressibility may be discovered with certainty. 

The soft places generally vary in size from that of a lentil up to 
that of a bean, and are found in the vicinity of the lambdoidal and 
posterior portion of the sagittal sutures, and sometimes encroach 
upon the sutures. The external occipital protuberance only is always 
spared. The diseased parts of the bones are elastic, their original 
convexities may be converted into equally as great concavities, and, 
when pressed, yield like a card laid across a hollow, or like an in- 
flated dried bladder. The pain attending a careful examination is 
not very great. 

The most frequent complications of this affection are spasms of 
various groups of muscles. The most dangerous of these is spasm 
of the glottis, whose undoubted yet by no means physiologically 
explained connection with craniotabes has already been discussed 
in detail on page 226. 

Besides attacking the occiput and the sinciput, rachitis invades 
the jaws. The teeth cease to grow, so that the patients get to be 
twelve and eighteen months old before they cut the first incisor- 
teeth. After these have appeared, they turn black, and, owing to the 
absence of enamel, crumble down. When the enamel is totally want- 
ing, the whole tooth down to the margin of the gum will disappear; 
sometimes it is only deficient on the apex, and the blackness is then 
restricted to that point. Rachitic children never go through regu- 
larly the five physiological periods of dentition {vide page 12), As 
is well known, at the end of each physiological dentition period the 
teeth are even in numbers. Hence, when a child after a period of 
eight weeks is found to have cut an uneven number of milk-teeth 
we may assume with certainty that a dentition period has been 
arrested, which, in the absence of other causes, such as chronic 
intestinal catarrh, febrile diseases, etc, is due to rachitis. As the 
disease disappears before the second dentition commences, these phe- 
nomena are not observed in the permanent teeth. 

Deficiency of the enamel, now and then met with in older chil- 
dren, is, according to the statements of some authors, due to the 
use of mercurial preparations, especially calomel. Should it actually 
be statistically demonstrated that the majority of these children had 
taken calomel, it would, very properly, in future, much restrict the 
use of this medicine. 



552 DISEASES OF CHILDREN. 

B.-RACHITIS OF THE THORAX. 

Glisson and his contemporaries correctly recognized the rachitic 
process, in the condition known as pigeon-breast, and subsequent 
authors devoted much of their time and attention investigating the 
manner of its origin; we therefore have much more explicit data 
concerninfj rachitis of the thorax than of craniotabes. 

It usually comes on somewhat later than softening of the occi- 
put, and many children who fortunately escaped the latter, and are 
already being carried about in a sitting posture, are attacked by 
rachitis of the thorax. Perceptible alterations are seldom observed 
in children under six months, while craniotabes may occur as early 
as the third month of life. The statement made in some of the text- 
books, that the pigeon-breast occurs from the first to the fourth 
year of life, is to be understood as meaning that children even four 
years old may be observed with this disease. But, after the com- 
pletion of the first dentition, rachitis never comes on in a child hith- 
erto perfectly healthy. 

The first symptom of rachitis of the ribs is a marked pain on 
touching or pressing the thoracic walls. Nurses say that "the child 
cries every time we raise it up, if ever so tenderly." Usually 
such statements are not much heeded by the physician, because 
most of them are based upon prejudice and incorrect views. The 
frequency of these complaints, however, struck me long ago, and I 
have convinced myself that it is by no means rare for children be- 
tween five and ten months old suddenly to cry out in pain when 
they are grasped with both hands under the axillae and lifted up, 
but, as soon as they are laid down, become tranquil again. Nay, 
more, it is not even necessary to lift them up ; slight pressure with 
the finger in the axillae, or on the thoracic walls generally, suffices 
to produce pain. If such a child is tenderly raised with one 
hand under the pelvis and the other supporting the neck, it will 
remain as quiet as if it had been lying on the pillow. In this 
manner, also, its bedding may be changed without giving it any 
pain. 

At this time, little or no hypertrophy can be felt at the sternal 
end of the ribs, at the junction of the costal cartilages and the 
bones. The sternal ends of the ribs do not become bulbous and 
hypertrophied, sufiicient to be detected by the finger, and later also 
by the eye, till several weeks have passed. Thus two uniform rows 
of buttons, the so-called rachitic wreath, appear on both sides of 
the thorax at a point corresponding with the end of the costal car- 
tilages. These buttons, so palpable from without, project still 



GENERAL DISEASES OF THE SECRETIONS. 553 

more markedly internally, forming large angular tubercles which 
encroach upon the cavity of the thorax. 

The thorax always becomes deformed in those cases where these 
rachitic hypertrophies have existed for some time. The sternum, 
which likewise undergoes softening, is pushed off more and more 
from the spinal column, and arches outwardly ; the xiphoid carti- 
lage becomes extremely movable, and, projecting, forms a deep pit 
in the scrobiculo cordis. In the severest grades of pigeon-breast, 
the costal cartilages, from their point of union with the sternum, run 
straight backward to meet the elongated transverse processes of the 
spinal column, and thus the ribs form a concavity instead of a con- 
vexity at their anterior ends. 

The diameters of the thorax become smaller from side to side, 
and larger antero-posteriorly, as is shown by the delineation, PL V., 
Fig. 2. The transverse diameter of the thorax assumes the shape 
of a pear, whose apex is supposed to be at the sternum. The ra- 
chitic row of buttons extends from the second to the eighth rib, the 
false ribs are forcibly pressed outward by the liver on the right, 
and by the stomach and spleen on the left side. The abdomen, in 
consequence of the constant presence of tympanitis, and of the 
shortening and curving of the spinal column, is tumefied, and of 
globular form, and much encroached upon by the distorted thorax. 
The spinal column is curved most during the sitting posture, and 
the globular shape of the abdomen is also on that account most 
striking in this position. When these children are laid upon the 
belly, and in this attitude raised up, the external curvature of the 
spinal column disapjDcars entirely, the spine assuming again its nor- 
mal form. In neglected cases, and where the rachitis has existed 
for several years, a permanent arching — not an angular curving — of 
the dorsal vertebrae laterally and posteriorly, may take place. 

The origin of the pigeon-breast is explained, in part, by press- 
ure of the atmosphere upon the soft ribs, and, in part, by the trac- 
tion of the diaphragm upon them, for which they serve as points of 
attachment. Having lost their firmness, the ribs are no longer able 
to withstand the constant dragging inwardly by the diaphragm. 

From rachitis of the thorax there originate (1), an alteration in 
the curve of the ribs ^ and (2), a^i arrest in the longitudinal groxoth 
of the ribs, the latter being a still more serious morbid condition, 
for it inevitably diminishes the pectoral space, and promotes that 
disease of the lungs known as acquired atelectasis, as has been 
already conclusively shown on page 251. 

The prognosis depends exclusively upon the condition of the 
lungs. When they are extensively involved in the atelectic process, 



654 DISEASES OF CHILDREN. 

and have become impermeable, then, of course, a serious catarrh in 
the remaining tissue suffices to induce labored breathing, and even 
dyspnoea, suffocating attacks, and death. In this complication, in 
fact, we have the usual cause of death in rachitic children, as Rom- 
hergy Guersant, and others, have remarked. 

C— RACHITIS OF THE PELVIS A^D OF THE EXTREMITIES. 

The pelvis does not become deformed before the rachitic child is 
able to walk, and then it is the result of scoliosis, or of an inequality 
of the lower extremities, after the manner of a distortion of the pel- 
vis in coxarthrocace. The important consequences of this alteration 
in the female are discussed sufficiently in detail in the standard 
works on obstetrics. 

Rachitis of the extremities is first recognized by a bulbous 
enlargement of the epiphyses of the radius and ulna at the wrist- 
joint. Its appearance at these points is at a somewhat later date 
than in the ribs, occurring usually during the last months of the 
first year of life. The degree of the rachitic affection is readily 
recognized at the wrist-joint, because here the epiphyses, in the nor- 
mal condition, are distinctly seen, and, being superficially situated, 
easily examined. 

In the cadaver, the lower extremities are found as severely af- 
fected with rickets as the upper ; but, since important hypertrophies 
occur at the knee and ankle-joints even in healthy children, rachitis 
does not produce at those jDoints such striking alterations of form 
as are seen in the wrist-joints. Of course, if the disease has reached 
the stage of deformity, the rachitis of the lower extremities will also 
be recognized in the gait, and it will not be necessary to imdress the 
child for the purpose of seeing it. The protuberances on the ends of 
rachitic long bones in reality represent their longitudinal growth. 
New cartilage is constantly formed on the epiphysis ; but no ossifica- 
tion of the newly-deposited mass takes place, and thus the soft carti- 
lage is pressed out by the contiguous bone, and by the traction of the 
muscles into unnatural breadth. Hence the bulbous enlargement 
constantly increases, for new cartilage is continually deposited. 

A comparatively diminutive state of all the cylindrical bones re- 
sults from this cessation of the longitudinal growth, and is most 
evident perhaps in the ribs, resulting, as has been stated, in the 
production of the acquired atelectasis. The shortening of the lower 
extremities is noticeable even years after recovery from the rickets, 
and these children are always smaller in stature than their healthy 
companions of the same age. 



GENERAL DISEASES OF THE SECRETIONS. 555 

The simple curvatures may become straight in the course of 
years ; the pigeon-breast may dilate completely, and the crooked 
sternum may also become straight. The infractions, however, leave 
behind them alterations of form which are permanent. 

As regards the functions of the I'achitic lower extremities, they 
are very much retarded. Rachitic children are not able to stand 
until they are two or three years old, and to walk until they have 
become older. Occasionally it happens that children, who had been 
able to stand before they were attacked by rickets, do not regain 
this power until many months after they recovered from the disease. 

There are few diseases that interfere with a child's use of its 
limbs for so long a time as rickets. Children may be ever so sick- 
ly, in the first year of life, but, so soon as they rally, if they do 
not become rachitic, commence to acquire the use of their limbs, 
and when eighteen months old, at the latest, begin to stand and to 
walk. 

I was once able to observe accurately the origin of the infractions. 
A child four months old was attacked by convulsions. I carefully 
examined its body, and found all the tubular bones straight ; still 
a rachitic row and hypertrophied epiphyses at the wrist-joints were 
perceptible. During the night the convulsions grew worse, and on 
the following morning one forearm and one tibia, both of them at 
the lower third, were bent at an obtuse angle, and the parts around 
were somewhat swollen and excessively painful. The fractured 
ends, of course, did not crepitate, nevertheless they were movable 
to a high degree. The denomination " fractured ends," strictly 
speaking, is not applicable to this condition, for no complete so- 
lution of continuity, but only a simple bending of the bones, oc- 
curs. 

Besides these especially characteristic signs of alteration of the 
bones, others no less constant also occur in other organs. With the 
appearance of the rickets, or some time before, excessive cephalic, 
and afterward general perspirations, invariably come on, as a result 
of which numerous affections of the skin become developed. Actual 
sudamina, or, still oftener, the so-called sudamina rubra, very small, 
opaque vesicles with red areolae appear so close to each other that 
often the entire body and the flexures of the extremities appear 
reddened, rough, and uneven. Later, when the patients begin to 
grow lean, the skin fades in color, becomes covered with a furfura- 
ceous, squamous exanthema, and the secretion of the perspiration 
ceases almost completely. 

The ligamentous apparatus, especially tlie capsule of the hip- 
joint, is extremely feeble and relaxed, so that children are able to 



556 DISEASES OF CHILDREN. 

touch their faces with the feet, and have an especial predilection for 
putting their toes into the mouth. 

As relates to the respiratory organs, spasm of the glottis, men- 
tion of which has already been made, when speaking of craniotabes, 
very frequently occurs, and, in addition, constant bronchitis, which, 
on account of the increasing carnification of some parts of the lungs, 
becomes severely aggravated. 

The digestion may, indeed, remain undisturbed during the en- 
tire course of the disease, but, when diarrhoea supervenes, the dis- 
ease, going on in the bones as well as in the system generally, 
becomes materially aggravated. It is a remarkable phenomenon 
that even young children, laboring under an intense form of rachi- 
tis and loss of appetite, tolerate cod-liver oil, and during its use get 
a better appetite and digestion. 

A few words more concerning the connection of the disease 
under consideration with tuberculosis and scrofula. Rickets was 
formerly called " scrofula of the bones," and it was regarded as one 
of the many localizations of the scrofulous cachexia. Jiiifz was the 
first to prove, by the histories and autopsies of twenty rachitic pa- 
tients, that the majority of them were not in the least scrofulous, 
and, since that time, we learn more and more to regard rickets as a 
sui-generis disease. 

Rickets, according to my extensive observations in many hun- 
dreds of cases, is an independent affection, which, under certain 
conditions, and at a certain age, may almost be induced at will in 
every child — more in one, less in another. Scrofulous children do 
not acquire it oftener than healthy ones : so the fact, as observed 
here in Munich, that rachitis and scrofula rarely occur together in 
the same person, must be accepted as proof that in this country the 
majority of rachitic children are not scrofulous. 

Etiology. — Remarkably few positive data are known concern- 
ing the causes of rachitis. In a great number of cases, the possi- 
bility of its being inheritable is not to be ignored. I know sev- 
eral families whose children, notwithstanding all possible care, and 
the most rational prophylaxis, always become rachitic at a cer- 
tain age, and suffer from it for years. In these cases, the father 
and mother usually display the peculiarly-shaped rachitic head, 
with its boldly-projecting tuberosities of the frontal and parietal 
bones. Elsasser and others also furnish us many positive instances 
on this point. The previous existence of syijhilis in the father has 
often been confessed to me, though it was completely cured long 
ago. Rachitis in children of wealthy families may probably be ex- 
plained in this manner. 



GENERAL DISEASES OF THE SECRETIOXS. 557 

In other instances it is developed with remarkable rapidity after 
acute diseases, such as measles, pneumonia, intestinal catarrh, etc. 

Of external causes, there is only one that can be maintained with 
certainty, namely, the want of fresh air, and this is unanimously 
stated by observers as the most frequent cause. This also explains 
the reason why rachitis occurs most frequently, and is most intensely 
developed, in the spring of the year, less so in the fall. Long con- 
finement in close and badly-ventilated rooms during the winter has 
caused it. Enjoyment of fresh air in the open street or public place 
in the summer cured it. Rachitis, for the same reason, is less fre- 
quently met with in southern climates. It is, however, well to say 
that even this assumption does not always serve as a satisfactory 
explanation. In Dorpat, where I now reside, rachitis is remark- 
ably seldom seen, and, when seen, only in a very mild form ; while 
in Munich, which is situated ten degrees farther south, it is one of 
the most common diseases. 

Prognosis. — As a simple alteration of the bones, rickets is never 
dangerous, and, in many instances, is arrested, and a final recovery 
takes place, after the conclusion of the first dentition. Its compli- 
cations, however, are extremely pernicious, and by these the greater 
portion of the rachitic children are carried off. 

Spasm of the glottis is apt to supervene at the very commence- 
ment of rachitis, when the soft occiput is as yet barely noticeable, 
and destroys the majority of children it attacks. It will be entirely 
impossible to prevent the degeneration of some pulmonary lobules, 
if the rachitis of the thorax makes much progress, for the lungs con- 
stantly increase in bulk, while the chest does not expand in propor- 
tion ; on the contrary, it even becomes smaller by the projection of 
the sternal ends of the ribs inwardly. When this degeneration, or 
carnification, or acquired atelectasis, involves a large extent of lung- 
tissue, severe dyspnoea and a mild catarrhal affection of the remain- 
ing normal tissue ensue, which almost invariably lead to death. 

Lastly, the curvatures and hypertrophies of the long bones may 
result in permanent deformities, shortening of one or the other ex- 
tremities, contraction of the pelvis, and displacement and serious 
disturbances of the functions. 

Treatment. — A countless number of remedies were employed in 
this disease before the introduction of cod-liver oil, and cort. aurant., 
rad. gentian rub., herb, absinth., rasura lig. quassise, calam, aromat., 
cinchona, Colombo, and the preparations of iron, were the ones most 
highly recommended. Externally, baths, affusions, and fumigations, 
with all kinds of aromatic herbs and their preparations, were em- 
ployed. Later, dyers' red (madder) came into use, principally recom- 
mended by Feiler and Wendt. Part of this red substance, as is 



558 DISEASES OF CHILDREN. 

known, becomes deposited in the bones, and it cannot be denied 
that it possesses a direct influence upon them ; but the alteration of 
color effects no increase in the calcareous deposits. 

3Ieisner believed he had observed that vaccination arrested the 
progress of rickets ; but liufz emphatically, with justice, denies it. 
De la Fontaine entertained the same views with regard to scabies ! 

The idea occurred to some that there was a real deficiency of 
bony substance, and they attempted to introduce it through the 
alimentary canal, Wurzer experimented in this direction with phos- 
phoric acid, which proved perfectly fruitless, and lately JSenehe pro- 
claimed pliosphate of lime as an antirachitic remedy. The reports 
of the experiments, wherever instituted with it, are by no means 
favorable, and it is now generally abandoned. 

Finally, in the year 1824, ScMtze, SchenJc, and Tourtual, in 
Germany, called the attention of the profession to cod-liver oil, 
while the French physicians became acquainted with it five years 
afterward through Bretonneaii, who was informed of it by a lay 
person from Holland. Since that time the favorable reports of ol. 
jecor. asell. have accumulated in such a manner that all the remedies 
heretofore used in this disease have been supplanted by it. 

A great deal has been disputed concerning the active principle of 
the cod-liver oil. Some believe that it simply acts as a respiratory 
remedy through the fat it contains ; others seek its effectiveness in 
the traces of iodine and bromine, and still others in its oleic acids, 
and the admixture of decomposing particles of liver which are found 
in all cod-liver oils. Since the experiments with pure fat, as well as 
those with minute doses of iodine or bromine, did not produce the de- 
sired effect, the last view seems therefore to be nearer the true one. 

It is best to give the brown oil pure by itself in increasing 
doses, at first a teaspoonful, later a tablespoonful once or twice 
daily. Most children habituate themselves so well to it in a few 
days that they come to look upon it as a delicacy, and will swallow 
several ounces of it at a draught, if they manage to get hold of the 
bottle. Rachitis may he cured by the use of cod-liver oil alone, 
even if the circumstances are in other respects unfavorable. To be 
sure, any possible improvement in the residence and nutrition will 
hasten the recovery. In this respect the following measures should 
be attended to : 

Pure, fresh air is, above all things, necessary. In damp houses, 
which in winter are not ventilated for many weeks, children acquire 
rachitis very quickly, in an intense form, and in these individuals 
cod-liver oil has only a slow and not a constant effect. 

Zealous attention to the skin is to be mentioned as a second im- 
portant adjuvant. The child should be bathed daily in an aromatic 



GENERAL DISEASES OF THE SECRETIONS. 559 

bath, and, in addition, the curved limbs should be washed every day 
with brandy. 

Most young children, even with craniotabes, tolerate cod-liver 
oil very well ; their restlessness is best palliated by douching the 
head with cold water, repeated every two or three hours. Elsasser 
recommends a pillow for the head, in which a pyriform hole is con- 
structed, with the apex directed downward. It is a great comfort 
to the little patient. On account of the profuse perspirations, ra- 
chitic children should not be laid upon feather-beds, but always on 
m^attresses of horse-hair, straw, or sea-weeds. 

Children who are still at the breast should be wet-nursed as long 
as possible, but, in addition to that, should be fed with milk soups. 
Cow's milk is the best nutriment for children up to the third year, 
and nothing will serve as a substitute for it ; it is to be given as 
plentifully as possible. Bernard^ a French physician, asserts that 
the women in Montbrun-le-Bains, as a protection against becoming 
pregnant again, suckle young pups. The latter invariably became 
rachitic •, they recovered, however, when caused to be suckled by 
bitches. Bernard then caused seven rachitic children to be suckled 
by bitches, and six of these, he claims, recovered. 

During the disease, an orthopedic treatment will hardly ever be 
of any benefit ; not till after it has been cured can the proper ma- 
chines and appliances be resorted to. 

Serious rachitic deformities, even in the adult, may sometimes 
be remedied by exsecting an accurately-calculated wedge of bone, 
and applying a proper apparatus. 

(2.) Tuberculosis aistd Scrofulosis. — A great deal has been 
disputed concerning the distinction between tuberculosis and scrof- 
ula. Some consider these two conditions identical ; others, again, 
assert that there is no resemblance whatever between them. 

It all depends upon the point of view from which the comparison 
is instituted. If regarded from the anatomo-pathological point of 
view, it may be affirmed with certainty that coxarthrocace and 
scrofulous intiammation of the joints, spondilitis, the affections of 
the cornea and conjunctiva, otorrhoea, and scrofulous diseases of the 
skin, are not usually due to tuberculosis of the affected parts. But, 
in practice, the physician continually notices the fact that the two 
diseases just mentioned are (1), by no means local troubles, but 
that they partly altei'nate with each other, partly occur simultane- 
ously on different parts of the body ; (2), that these diseased chil- 
dren are always the progeny of tuberculous parents ; and (3), that, 
after the disappearance of the scrofulous affections, which usually 
occurs about the commencement of puberty, they always become 
more or less intensely tuberculous. 



560 DISEASES OF CHILDREN. 

In practice, then, the physician cannot do otherwise ; he must 
assume the existence of an intimate connection between the two 
cachexise. But the pathological anatomist, who devotes his atten- 
tion more to the morbid products than to their origin, may very 
well consider the resulting alterations separately. Still, even path- 
ological anatomy shows, in very many instances, the material con- 
nection between the two. In almost all infantile cadavers, which 
reveal any scrofulous lesions, or affections of the bones or of the 
lymphatics, there will also be found, generally in the bronchial 
glands, one or more large, yellow, cheesy tubercles, which are to be 
looked upon as the root, the starting-point, of the numerous periph- 
eral scrofulous aflFections. 

Havinw thus established the connection between the two ca- 
chexise, we may now pass on to their separate consideration : (a), 
tuberculosis, and (b), scrofulosis. 

K.—TIIE TUBERCULOUS CACHEXIA. 

Since, in the entire plan of this work, the diseases have been 
generally treated of according to the individual organs, and not 
according to the nature of the pathological alterations, tuberculosis 
has therefore already been frequently discussed ; and, in order to 
avoid repetitions, we refer the student to the former sections. Tu- 
berculosis of the lungs will be found described on page 565, that of 
the bronchial glands on page 567 ; of the brain, on page 271 ; of 
the ear, on page 368 ; of the mesenteric, on page 154 ; of the kid- 
neys, on page 379 ; tuberculous peritonitis, on page 188. It remains 
only to speak of the general sj^mptoms of tuberculosis and of its 
etiology. The treatment, finally, may be comprised with that of 
scrofula. But it is also presupposed that a knowledge of the gen- 
eral views of tubercles, their origin and retrograde formations, has 
already been acquired by the student. 

General Symptoms op Tuberculosis. — "VVlien single organs 
are severely attacked by tuberculosis, the functional disturbances 
of that organ will naturally become very apparent, and will eclipse 
the symptoms peculiar to the cachexia, as is particularly observed 
in tuberculosis of the lungs, of the brain, and of the peritonaeum. 
Generally, however, when the intensity is less markedly stamped 
on a single affected organ, the following general symptoms make 
their appearance : 

The color of the face is usually pale, sallow, and anaemic ; the 
cheeks display a unilateral circumscribed redness, which disappears 
after a few hours. Severe disturbances of the circulation in the 
lungs, or very large bronchial glands, may also induce serious dysp- 



GENERAL DISEASES OF THE SECRETIONS. 561 

noea, followed by death. Most tuberculous children bear a pain- 
fully-sad expression in their countenances ; the lethargic movements 
of the lids, and of the globe of the eye, with its bluish sclerotica, 
give them an extremely peculiar appearance. 

The /ever, consisting in an increased temperature of the skin and 
accelerated pulse, is a constant symptom in general tuberculosis. 
But a distinction should be made between the frequently exacer- 
bating vascular excitement of chronic tuberculosis and of hectic 
fever, which comes on in the last stage, and continues till death 
ensues. Tuberculous children frequently have a hot, dry forehead 
and hands, increased thirst, and high temperature of the skin, espe- 
cially toward evening ; but all of these symptoms disappear after a 
few hours, and often do not recur for weeks. The nutrition of the 
children does not materially suffer from these transient vascular 
excitements ; the latter may even disappear entirely if no new 
tuberculous aggravations ensue. 

The case is entirely different with hectic fever. The pulse, 
which at first is hard, later on small and compressible, rises to 150 
beats and more per minute. Every evening an exacerbation en- 
sues, but no complete apyretic condition ever takes place again. 
This fever may last for months, and even years ; in the latter case, 
naturally, it is less intense, but it induces emaciation of the child 
down to a mere skeleton, and does not leave it until death. Toward 
the end, the temperature of the skin, according to the sense of 
touch, does not rise in exact relation to the acceleration of the 
pulse ; on the extremities it is more apt to sink below the normal 
state. Yet the thermometer shows a high temperature to the very 
end. 

At the commencement of tuberculosis, or when the sick child is 
not watched long enough by us, this fever is apt to mislead us in our 
diagnosis. The vespertine exacerbations may simulate an intermit- 
tent ; but this error soon becomes manifest from the failure attend- 
ing upon the use of large doses of quinine. Occasionally, the diag- 
nosis vacillates, for several weeks, between acute tuberculosis and 
typhus fever, and this is all the more likely to happen in children, 
as infantile typhus has less well-pronounced symptoms than typhus 
fever in the adult. Even when the tuberculous pulmonary symp- 
toms are more predominating, it is often a question whether the 
continuous fever may not be prolonged by a pneumonia that runs 
an irregular course. 

The nutrition suffers markedly in all tuberculous children, and 
an alarming emaciation soon ensues, which, however, as a diagnos- 
tic sign, is of no great importance, as it is also produced by all 
febrile, protracted infantile diseases. Acute tuberculosis of chil- 



562 DISEASES OF CHILDREX. 

dren under one j'ear of age is an exception in this regard. These 
children remain phirap almost until death, especially if they nurse 
at the breast of their mother ; but the constant hot skin, and the 
incessant cough, with which a great deal of white froth is expelled 
from the mouth, permit one to form a diagnosis of acute tuberculo- 
sis with the utmost probability, and the autopsy, in most instances, 
confirms this approximative diagnosis. 

When thrush forms upon the mucous membrane of the mouth, 
in older children suffering from tuberculosis, a speedy lethal end 
may be predicted almost with certainty. The tongue presents but 
little that is characteristic. The appetite is frequently still fair, 
even when hectic fever has already set in ; on the whole, it is not 
noticeable that these children become more emaciated, or live long- 
er, than others that suffer from prolonged dj^spepsia. Diarrhoeas 
are frequently observed, but they are not always due to ulceration 
of the intestines, in most instances being the effects of simple ca- 
tarrh of the intestinal mucous membrane. 

The skin, in chronic tuberculosis, is never normal ; it loses its 
original smoothness, and becomes flabby and corrugated in conse- 
quence of the diminution of the subcutaneous adijjose tissue. A f ur- 
furaceous desquamation frequently takes place upon the trunk and 
neck, which disappears for some time, but soon returns again, and 
becomes complicated with pityriasis versicolor. The markedly 
desquamating, denuded spots perspire but little ; the others, how- 
ever, as an offset, all the more profusely. The perspiration, espe- 
cially about the head, is seen to gather in large drops, wetting the 
hair and j^illow. Conformably therewith, sudamina are often ob- 
served in large numbers. 

General oedema does not occur in simple tuberculosis ; in the 
last stage, however, a slight oedema about the ankles and dorsum 
of the feet takes place. In infants it is a safe cardinal point, for it 
is almost exclusively seen in tuberculosis, the physical examination 
of the chest usually supplying no satisfactory signs. Occasionally, 
a partial oedema of the face, and of the upper extremities, origi- 
nates, and is due to local derangements of the circulation. Marked- 
ly enlarged bronchial glands have been observed to exercise pressure 
upon the vena cava descendens, and thus cause stagnation in its 
vascular sphere. 

Chronic tuberculosis either retains its character till death, the 
patients dying from the effects of the fever, of the emaciation, and 
of the exhaustion, or the lethal end is accelerated by miliary tuber- 
culosis and acute hydrocephalus. 

The prognosis need not be put down as absolutely fatal, even in 
markedly advanced tuberculosis, for cases occur in which, notwith- 



GENERAL DISEASES OF THE SECRETIONS. 563 

standing all the unfavorable signs, an arrest nevertheless ensues, 
and, after many years of sickness, perfect nutrition and progressive 
development finally take place again. 

Etiology. — There is no disease that is so positively inheritable 
as tuberculosis, and this inheritability is so clearly demonstrable, 
in many cases, that I suspect it is the only and true cause of the 
cachexia. True, children bring no ready developed tubercles with 
them, into the world, and, so far as I am aware, none were ever 
found at autopsies of the new-born, but tuberculosis may fully de- 
velop itself in the first few Aveeks of life ; so that miliary, or even 
large tubercles, may be found in an infant that lived only two or 
three months. 

The intensity varies very much in degree, according to the kind 
of constitutions the parents have. If only one of the parents is 
tuberculous, and the other comes from a perfectly healthy family, 
then all the progeny of this alliance will not be tuberculous, not 
even scrofulous. It fares precisely with the inheritability of tu- 
berculosis as with the foi'mation of the body. When the father has 
black hair and brown iris, the mother blond hair and blue iris, then 
the children usually do not have a mixture of these variegations 
of color ; some of them will take entirely after the father, others 
after the mother. Now, when the father is tuberculous and the 
mother healthy, or 'vice versa, it may very well happen that some 
of the children will be perfectly sound, and others decidedly tu- 
berculous. Frequently, however, a weakening of the cachexia, 
which manifests itself by mild scrofulous forms, is observed on 
the one hand, and, on the other, slight scrofulous affections and 
a disposition to bronchitis, chronic blephai'itis, and phlyctenular 
conjunctivitis, occur in apparently perfectly healthy children. 

Now, by " crossings " between markedly and feebly tuberculous 
patients and healthy persons, a number of gradations originate ; 
and, owing to the limitless extent to which the cachexia has now 
attained, but very few families have remained perfectly free from 
all dispositions to tuberculosis, and from scrofulous symptoms 
pointing to it. The chief difticulty that has to be overcome, when 
the attempt is made to explain the origin of tuberculosis by the in- 
heritability alone, is this : that, especially in the milder grades of 
tuberculosis, some circumscribed, perhaps even cretaceous tubercles, 
are not diagnosticable. Very frequently, in fact, the residue of a 
former tuberculous process, of which no one had the least idea, is 
found in the apices of the lungs or in the bronchial glands, at the 
autopsies of the strongest, best-developed individuals Avho suc- 
cumbed to some acute disease. Consequently, it is not possible to 
maintain, with any degree of certainty, that there is no such con- 



56J: DISEASES OF CHILDREN. 

dition as hereditary disposition, and that the tuberculosis, in a 
given case, was produced entirely by external causes. 

The following are generally considered the external causations 
of tuberculosis : bad air, confinement in close, imperfectly-venti- 
lated, dusty rooms, damj? houses, and bad food, by which, living 
exclusively on rye bread and potatoes, and a lack of animal food, 
is understood. But if any deductions regarding these external 
causes can be drawn from a large practice among the poor, such 
as mine has been for several years past, then it becomes pretty 
evident that tuberculosis is very rarely generated by them ; and, 
on the other hand, it is often found where these external causes are 
entirely absent. 

The circumstances are most strikingly manifest when children 
of different parents grow up together in one family ; a very fre- 
quent occurrence in the case of illegitimate children who are not 
retained by their mothers, but are kept at board in a strange fam- 
ily. Now, when the family that has taken charge of an illegitimate 
child have children of their own, all the children will live together 
under the same circumstances. They sleep in the same rooms, they 
eat from the same dish, they are alike neglected as regards clean- 
liness, and yet it has been observed scores of times that the strange 
child remained perfectly well, while their own children are the 
whole year through under treatment for scrofulous affections, or 
the contrary was the case. Now, when these facts recur so often 
that every busy physician is able to count them in large num- 
bers, the faith in external causes, unwholesome food, bad air, and 
inattention to the skin, becomes more than vacillating, since, owing 
to the great masses of proletarians living crowded together in large 
cities, tuberculosis should be still more frequent than is actually 
the case. Entire houses, and even streets, in which these poor 
people are huddled together, ought to be tuberculous, a circum- 
stance which, so far as I am aware, has never been observed in 
any city. 

These external causes may be of the utmost importance for chil- 
dren who bear the germ of tuberculosis, increasing and aggravating 
the kind as well as the number of the single exacerbations ; where, 
however, no causes exist, the children certainly develop more slow- 
ly, remain pale, lean, and small, yet they will not exhibit tubercu- 
losis, nor even scrofulosis. 

Let us consider the affair from the opposite direction. In chil- 
dren of the opulent classes these external causes are entirely ab- 
sent, and thus fewer children of this class should be tuberculous than 
of the poor who may have become so through the unfavorable cLr- 



GENERAL DISEASES OF THE SECRETIONS. 565. 

cumstances under which they are situated. But, so far as the 
general survey reaches (these circumstances cannot be calculated by 
per cents.), it is found that the children of the rich are not less fre- 
quently tuberculous than those of the poor ; nay, more, the disease 
seems to occur predominantly in the former class. It follows, 
from this fact, that by far less weight should be placed upon bad 
diet, residence, and inattention to the skin, than upon hereditary 
disposition. 

Although the external causes are of but slight importance in 
regard to generating tuberculosis in healthy individuals, it must 
nevertheless be acknowledged that they become active agents where 
the hereditary disposition exists. In this respect, however, pre- 
ceding diseases are of more importance, esj^ecially measles, syphilis, 
whooping-cough, and typhus fever. After these maladies, tuber- 
culosis suddenly develops itself in children who formerly were ap- 
parently perfectly well. It most frequently comes on after measles ; 
it supervenes upon the latter so often, that the assumption that 
every child with an hereditary disposition attacked by measles sub- 
sequently becomes tuberculous, or at least scrofulous, seems justifi- 
able. This tuberculosis following upon measles distinguishes itself, 
from that of the spontaneously originated, by the fact that an ar- 
rest, and finally even a decided improvement, is much more fre- 
quently observed in it than the latter kind. 

(1.) Tuberculosis of the Lungs and Bronchial Glands. — 
Since the dyscrasiae, as collective diseases, have been subjected to a 
detailed discussion in the preceding section, we may now complete 
the subject by delineating the pathological anatomy and symp- 
tomatology of pulmonary tuberculosis, while the etiology and con- 
sideration of the general disease will be treated of along with the 
dyscrasise. 

Pathological Anatomy. — At the commencement of pulmonary 
tuberculosis, numerous white, dense nodules are seen on the cut sur- 
faces which, as Hindfleisch has clearly demonstrated in Ziemssen's 
*' Handbook of Special Pathology," vol. v, always have their site at 
the transition point between the smallest bronchial and the pul- 
monary acini. They represent a cellular, bloodless infiltration of the 
pulmonary parenchyma, and never attain to any higher organiza- 
tion, but undergo a retrograde metamorphosis of cheesy softening. 
Calcification is less often met with in infantile life than in adults. 
The minute tubercular nodules increase in numbers and size, enlarg- 
ing into foci, in which small bronchi both transversely and longi- 
tudinally are found. The cells of the parts first affected soon dis- 
appear, and the entire pulmonary tissue is transformed into a diffused 

8r 



566 DISEASES OF CHILDREX. 

molecular infiltration, while on the periphery of the same new 
alveoli fill up with epithelial cells {BichVs desquamative pneumo- 
nia). The caseous transformation may take place so rapidly that 
the several tubercular nodules remain ununited, and thus form 
caseous lobular conglomerations. In children, larger infiltrations, 
caseous lobular pneum^onia, generally take place rapidly, hut they 
do not always occur in the apices of the lungs, being often met in 
the lower lobes. 

In these large tubercular infiltrations, the process of softening 
and degeneration can be studied to the best advantage. The tuber- 
cular mass, which has finally attained to a semi-fluid consistence, is 
evacuated through a bronchus, and a partly or completely empty 
cavity remains, in the walls of which new tubercles may be deposit- 
ed, and then, by the softening of the latter, the cavity is still more 
enlarged. Thus irregular, excavated cavities, provided with numer- 
ous prolongations, finally result, and are filled up with a dirty, crum- 
bling, yellow, or gray pus. Sometimes several small ones, then again 
a single one, large enough to occupy the whole lobe, may occur. 

[The contents of these tubercular cavities, when evacuated, by 
expectoration or otherwise, consist of disintegrated cheesy detritus 
and tubercle bacilli, varying in numbers {S7nith). In some cases a 
few only are found, in others they are numerous, and collected in 
groups and masses. And, since the discovery of the presence of the 
bacillus in tubercular disease, it has been claimed that tuberculosis 
may be communicated from one person to another by the organism 
acting as a medium of infection. The discovery that bacilli are 
present in the air expired by consumptive persons, and in the ex- 
pectoration, has been claimed to be the manner in which the disease 
was transmitted. The matter, however, is still sub Judice.] 

In this connection it may be well to remark that the ulcerative 
action going on in a cavity seldom extends to adjacent lobes, gen- 
erally leaving the demarkations naturally existing between them un- 
injured. Large caverns always communicate with some bronchus, 
whose open mouth is seen adhering to and terminating in the walls 
of the cavity. Occasionally obliterated vessels, or remnants of par- 
enchymatous tissue, run like strings or bridges across the cavity. 
These vessels, however, are invariably obliterated, for haemoptysis 
is so extremely rare in children that it is not mentioned as ever 
having been observed. So, too, the rupture of a cavern into 
the pleural sac, with pneumo-thorax resulting therefrom, to my 
knowledge, never occurs in tuberculous children. That the pul- 
monary parenchyma surrounding a cavity is never perfectly normal, 
but solidified like cicatricial structures, or in a state of gray or 



GENERAL DISEASES OF THE SECRETIONS. 567 

red hepatization, containing' more or less tubercles, is well known. 
QEdema is also frequently met with, especially in the lower lobes, 
while a vicarious emphysema usually involves the upper lobes. The 
bronchi which communicate with the cavities contain a yellow, crum- 
bling pus like that found in the caverns, while the rest exhibit a 
swollen and injected mucous membrane. According to Hasse, the 
branches of the pulmonary artery leading to the tubercular cavities 
and infiltrations become obUterated, but new ones are formed in the 
parts of the lung that have suffered a loss in their principal vascular 
network. This increased vascular supply comes from the bronchial 
arteries and in part from the intercostal, the blood being carried off 
again by the bronchial veins and vena azygos. A disturbance of the 
circulation ensues, with which the partial dilatation and unusual de- 
velopment of the subcutaneous veins may have some connection. 

Cavities, as is well known, may heal by calcification or by cica- 
trization. For both methods of healing, a number of years of time is 
undoubtedly necessary, and this readily accounts for the rarity with 
which they are observed in the autopsies of infantile cadavers. Cal- 
cification never occurs in children ; dense, puckered places, on the other 
hand, are often seen conjointly with still-existing cavities, and are, 
most probably, to be regarded as the cicatrices of smaller cavities. 
The tubercular lung of an infant is distinguished from that of the 
adult by the absence of pigmentation. 

The hronchial glands are much more frequently the site of tuber- 
cles than the lungs. This is invariably the case when tuberculous 
degeneration exists in the lungs ; but often, even where they are not 
implicated. Here the large yellow tubercle principally occurs, while 
the aggregated clusters of small tubercle are rarer, and the miliary va- 
riety is scarcely ever observed. 

Generally, the whole gland degenerates into a large yellow tuber- 
cle, and attains to the size of a small hazel-nut, and even to that of a 
walnut. The tuberculosis mostly implicates several glands, so that 
the bifurcation of the bronchi becoiiies surrounded by a large tuber- 
cular mass. Only those glands l^ang external to the lungs attain to 
a considerable size : those accompanying the bronchi within the lungs 
barely become larger than an almond, or dispose themselves in semi- 
lunar channels about the bronchus. The glandular parenchyma, as a 
rule, has wholly disappeared, and nothing but a capsule, the former 
enveloping membrane of the gland, remains, to which a yellow tuber- 
culous mass adheres all around. These seem to be less disposed to 
softening ; remarkably seldom, at all events, are soft tubercles found 
in the glands, but, when that process does take place, it may begin in 
the centre as readily as at the periphery. In older children a partial 



568 DISEASES OF CHILDREN. 

calcification may also occur. The influence of the tuberculous bron- 
cliial glands upon the adjacent organs is twofold, as Hilliet and 
Barthez very correctly have pointed out. They say that glands act 
either (1) by compression, or (2) by firm adhesions with the contiguous 
organs and consecutive perforation. 

(ad 1.) Anatomists di\'ide the glands that are situated external to 
the lungs into (a) tracheal glands at the side of the trachea down to its 
division ; into (J) bronchial glands, lying between the bifurcation ; 
into (c) cardiac glands, lying upon the base of the heart and large ves- 
sels ; and into {d^ oesophageal glands, within the mediastinum posti- 
cum, in the neighborhood of the oesophagus. All these glands may 
undergo tuberculous degeneration and enlargement, and then press 
upon the adjoining organs. 

As regards the compression of the vessels, we find those which are 
liable to it to be the superior vena cava, the pulmonary artery, the 
pulmonary veins, and the vena azygos. Instances of the total obUter- 
ation of these veins by this means are recorded. I myself have never 
met Avith such, but only remember to have seen a constriction of a 
pulmonary vein with simultaneous tubercular degeneration of the bron- 
chial glands. Compression of the vessels may give rise to haemorrhage 
and oedema. Thus, for example, according to the authors above 
quoted, compression of the vena cava superior jDroduced a haemorrhage 
into the arachnoid sac, and oedema of the face. Pressure upon the 
pulmonary vein may very readily cause oedema of the lungs. 

Impressions upon and Battenings of the trachea and its bifurca- 
tion are sometimes found, and are also produced by tubercular glands. 
They are not, however, capable of efi'ectiug any decided diminution of 
their cahbre. Compression of the nerves is of greater importance, 
especially of the pneumogastric nerve. Sometimes the glands grow 
so closely around them, that it becomes an actual impossibility for the 
anatomical knife to separate them. Nevertheless, the nervous func- 
tion does not seem to be interfered with, for, were it otherwise, more 
marked disturbances of the circulation and of the respiration would be 
observed in glandular tuberculosis than is actually the case. Compres- 
sion of the oesophagus seems to occur but very rarely ; a simple lateral 
displacement is sometimes observed. 

(ad 2.) The bronchial glands within and outside of the lungs may 
become ifttimately united with the bronchi, and perforation of the 
walls of the bronchi may ensue from the softening that follows. Ac- 
cording to Hilliet and JBarthez, non-softening, hard, tubercular nodes 
are also capable of producing ulceration of the rings of the bronchi, 
and thus occasion perforation, a condition that has hitherto received 
hut little attention from the pathological anatomist. In the lung 



GENERAL DISEASES OF THE SECRETIONS. 569 

itself it is very difficult to distinguish a cavity from a perforated bron- 
chus in a suppurating bronchial gland. These pseudo-cavities are 
always situated near the roots of the lungs, and outwardly their excava- 
tions are in connection with the rest of the tuberculous masses of the 
degenerated glands. 

The authors referred to also speak of a tuberculous perforation of 
the pulmonary artery, and of the oesophagus, of which I have no per- 
sonal experience. 

Symptoms. — First of all, as regards the physical examination, it 
is important to understand that the percussion should be performed 
lowly ; and the strokes follow each other very slowly, for otherwise the 
less-marked dulness will invariably be overlooked. In miliary tuber- 
culosis, where both lungs are equally permeated by the minute tuber- 
cles, percussion, of course, affords less information; the percussion- 
sound in general is a little more tympanitic, but no inequality in the 
two pectoral moieties can be detected. The same holds good with 
tuberculosis of the bronchial glands, which are overlapped by the 
lungs and roots of the large vessels, and thus totally escape the 
physical diagnosis. On the other hand, extensive tuberculous infiltra- 
tion may very readily be detected by careful percussion, but, as has 
already been stated, when treating of the pathological anatomy, the 
apices of the lungs are not so exclusively the site of these infiltra- 
tions. A circumscribed dulness is very frequently found farther down 
or laterally, which is also referable to tuberculosis, although in 
adults it seldom occurs in this manner. If caverns have already 
formed and evacuated their contents by the bronchi, the flat percussion- 
sound becomes a little more sonorous, and acquires a tympanitic pitch, 
a condition that by no means indicates improvement nor diminution 
of the tuberculous infiltration. 

Nothing characteristic is detected by auscultation ; the bronchial 
catarrh always attending upon this disease gives rise to far-diffused, 
large and small sibilant rales, which differ in no respect from those of 
a simple bronchitis. In large tubercular solidifications of the pul- 
monary substance there is always bronchial respiration, strong con- 
sonance of the voice and of the cough, and distinct abnormal propa- 
gation of the cardiac sound to parts of the lungs at a distance from 
the heart. Occasionally crepitating rales, or merely roughened res- 
piration, is heard at the margin of the dulness. The cardiac impulse 
is remarkably strong in all tubercular children. When a solid tuber- 
culous infiltration liquefies, and cavities are formed, the auscultatory 
symptoms likewise become changed, as has already been pointed out 
when treating upon percussion. Cavernous gurgling and ritles now 
supervene, and the breathing becomes cavernous. Cavities, however, 



570 DISEASES OF CHILDREN. 

in small cliildren, as a rule, are not of such a size tliat these symptoms 
should always appear, and be perfectly characteristic. 

As regards the functional symj^toms, these will be found to be of 
various descriptions. The respiratory acts are almost always acceler- 
ated, most rapidly in febrile, acute tuberculosis, where the two factors, 
(1) the fever, and (2) mechanical obstruction in the air-passages, act 
in combination. They then rise from sixty to eighty in the minute. In 
chronic tuberculosis the acceleration is barely perceptil^le, and scarcely 
any dyspnoea is present. But, in the rapidly-developing and pro- 
gressive form, great dyspnoea, even orthopnoea, and labored breathing, 
participated in by the alae nasi, may become superadded. This, how- 
ever, is to be ascribed more to the concomitant pleuritis and partial 
tuberculous pneumonia than to a constriction of space, in consequence 
of the tuberculous deposit. In general it may be assumed that the 
more acute and diffused the process in the lungs, the more accelerated 
and embarrassed are the acts of respiration. 

The cough is the most constant of all the symptoms, for it is never 
absent altogether ; it is feebler and less noticeable in acute miliary 
tuberculosis, where the same process in other organs, particularly in 
the brain, reduces the irritability of the nervous system to such an 
extent that these hydrocephalic children often wiU not cough for 
many days, although the post-mortem examination may show that 
both lungs are found permeated by miliary tubercles, and the bron- 
chial glands metamorphosed into cheesy masses. 

The cough is not only the most constant, but also the earliest of 
all the symptoms. It never ceases completely during the entire 
course, although there may be short remissions which are liable to 
mislead one to the formation of a deceptive prognosis. At first it is 
dry, short, and hacking, but reciu's frequently ; later, when large ex- 
tents of bronchi are im^Dlicated, it becomes moist, and is attended 
by convulsive paroxysms. These paroxysms have great similarity to 
those of whooping-cough, but the characteristic, loud, and prolonged 
inspiration at the end of the cough is always absent ; nor does the 
expectoration of large quantities of glairy mucus set in after several 
weeks. These spasmodic coughs, as a rule, have their foundation in 
the tuberculous enlargement of the tracheal glands, which exercise a 
constantly-increasing pressure upon and irritation of the trachea, and 
consecutively upon the lar^mx. It may also be occasioned by profuse 
secretion alone, as is often enough observed in adult patients suflFer- 
ing from simple broncho-blennorrhoea. When the latter cause exists, 
the paroxysm ceases as soon as the mucus has passed the larynx, but 
this cannot be so easily decided in children, since they immediately 
swallow it. In tuberculosis of the bronchial glands, on the other 



GENERAL DISEASES OP THE SECRETIONS. 571 

hand, the paroxysms may continue for an indefinite time, and exist 
without any expectoration, and, as a rule, cease only when the ex- 
haustion has become extreme. 

The expectoration^ which in adult tuberculous patients supplies 
such an excellent index, cannot be relied upon at all in children up to 
the fifth or sixth year, for they invariably swallow the mucus coughed 
up from the larynx. But occasionally, even in young children, after 
a violent paroxysm of coughing', a white, fine-frothy foam will be seen 
to rise to the tongue, and even between the lips. This, however, can 
only be regarded as simple secretion of the bronchi affected with 
catarrh, and is by no means pathognomonic of tuberculosis. Children 
over seven years old, in whom, before the age of puberty, phtliisis 
pialmonalis is very rare, expectorate like adults, and the pus evacuated 
from the vomicge is in all respects similar. The rare occurrence of 
hemoptysis has already been particularly mentioned, in connection 
with heemorrhage of the lungs generally, on page 258. 

If the children are large enough to indicate the place where they 
feel the pain, they will almost always describe its site to be at the 
prsecordia or the sternum, only extremely rarely in the lateral parts 
of the thorax. It is absolutely necessary to ascertain whether any 
pains more or less violent exist, for the purpose of instituting a scien- 
tific treatment, for the more intense they are, and the greater the 
restlessness occasioned by them, the more rapidly the children sink. 
As tuberculosis is seldom limited to one lung, the alterations observed 
in the decubitus of such children are, therefore, less constant. They 
mostly lie on the back, and only very seldom choose a constant lateral 
decubitus. It is remarkable that, notwithstanding the extreme ema- 
ciation, the long duration of the disease, and of the continued fever, 
they rarely and only at a late date get bed-sores. The walls of the 
thorax exhibit a degree of emaciation disproportionate to that of the 
rest of the body, and a development of the subcutaneous veins takes 
place, and may be regarded as characteristic of tuberculosis. These 
veins, especially in the neighborhood of the sternum, from the first to 
the third rib, become largely dilated, and may swell up to tlie width 
of one line. 

In all chronic diseases in which any impediment to the circulation 
of the blood exists in the lungs, consequently in extensive tubercu- 
losis and cardiac affections in particular, a peculiar bulbous sweUing 
of the tips of the fingers is observed, by which the nails become 
curved forward like claws. In the highest grade of this curving the 
fingers acquire the appearance of drumsticks. In this we possess a 
very valuable sign, because tljis bulbous thickening of the ends of 
the fingers is never congenital, and is never observed in healthy 



572 DISEASES OF CHILDREN. 

children, but always denotes the existence of a high degree of 
stasis in the right side of the heart, which, as a rule, has its cause in 
the lungs. 

Markedly enlarged bronchial glands, as has already been observed 
in speaking of the pathological anatomy, sometimes give rise to 
oedema of the face — a condition that is to be ascribed to local dis- 
turbances of the circulation, because, in dropsies originating in the 
dyscrasia3, the feet are well known to swell first, and oedema of the 
upper extremities and of the face does not supervene untU a long time 
afterward, while in this case that of the face alone is present. JRilliet 
and Barthez have shown, by several dissections in such cases, that 
compression of the vena cava by the enlarged glands has actually 
taken place. There is then also found a marked dilatation of the 
subcutaneous veins of the neck, and slight cyanosis of the lips and 
eyelids. 

Pulmonary tuberculosis runs its course either as acute miliary tu- 
berculosis, in which case the same process is also found established in 
other organs, especially in the brain and upon the peritonaeum, and 
the various symptoms emanating from the other organs, completely 
overshadowing those of the lungs, or it runs a chronic course as in the 
adult, under the signs of phthisis pulmonalis. The first form will be 
discussed once more in speaking of the cachexise ; the second has a 
duration of from two montlis to two years, and may also be arrested. 
I know children, the progeny of demonstrably tuberculous parents, 
who, in the early years of life, exhibited decided signs of developed 
pulmonary tuberculosis, such as distinct dulness over one or the other 
part of the thorax, bronchial breathing, sibilant rales, intense protract- 
ed bronchitis, emaciation, fever, etc., and nevertheless recovered, to all 
appearance, completely : the nutrition became reestablished, the ap- 
pearance of the child blooming, the fever and cough gradually sub- 
sided ; but the dulness remained, and, with the least disturbance of 
the general condition, a new and obstinate bronchitis always recurred. 
But finally, in some cases, the process becomes general, and then the 
phthisical children perish under the symptoms of miliary tuberculosis. 

In regard to the treatment, the reader is referred to the precepts 
which will be recommended for tuberculosis in the section on the 
dyscrasiae. 

(2.) Carcinoma of the Lungs and op the Mediastinum 
Anticum, — Carcinoma in general is an extremely rare affection in 
children, and that of the lungs in particular has been observed but a 
few times. In most instances carcinoma of the lungs was found in 
the cadaver, along with cancerous deposits in other organs, in the 
form of white or grayish-red nodules of the most variable sizes. The^ 



GENERAL DISEASES OF THE SECRETIONS. 573 

are situated both in the deeper portions and upon the periphery of the 
lungs ; thej are flattened doAvn when deposited close to the pleura, 
and, like cancer o£ the hver, become umbilicated in the centre. The 
symptoms observable during life are reduced to bronchitis and dysp- 
noea, and are usually supplanted by those of carcinoma in other organs. 

Carcinoma of the mediastinum antieum I have observed tvpice — 
once in a boy five years of age, and once in a boy six years of age. 
Since, in both cases, the whole anterior mediastinum was filled up with 
it, and the pleura, lungs, and pericardium were united by it, a descrip- 
tion of the symptoms at this place will therefore not seem improper. 

The development of this carcinoma seems to be tolerably rapid ; 
at any rate, both of these children manifested the signs of embarrassed 
respiration for a few weeks, and yet, at the percussion that was soon 
after performed, a marked dulness was already observable over the 
sternum, extending laterally to both sides of it. The main index is, 
therefore, the aforesaid dulness, which, in the course of the malady, 
rapidly increases, not only by the growth of the carcinoma, but 
also by the dropsical efi'usion which is poured out into the pleural 
sac. That the exudation which gives rise to the dulness is not of a 
fluid natm'e, may be very easily demonstrated. The cardiac sound is 
heard over it almost as loudly as when the heart itself is auscultated ; 
the sibilant rales, too, originating in the catarrhal bronchi, are dis- 
tinctly audible over the cancerous tumor. The functional disturb- 
ances mainly depend upon the direction in which the cancer has most 
extended. The large venous trunks must have been compromised in 
both the cases I saw, for oedema of the face and hands was present, 
and the veins of the neck were markedly dilated. The children suf- 
fered from constant orthopnoea, on account of the extremely distress- 
ing compression of the anterior sections of the lungs, and breathed 
easiest when they curved the back and flexed the head forward, which 
attitude was also retained during sleep. The dorsal surface of the 
thorax gives, in these cases, a sonorous tympanitic percussion-sound, 
and, as this part of the lung must perform a double duty on account 
of the compromised anterior portion, the respiratory sounds are heard 
extremely intensified, and frequently masked by sibilant rales. The 
heart is displaced outwardly and downward, and, in one of the cases I 
saw, a blowing systolic murmur was heard without any material alter- 
ation of the heart or its valves being found at the autopsy by which 
that murmur could be explained. The pulse is very much accelerated, 
the appetite not wholly gone, and the emaciation, consequently, never 
becomes so extreme as in tuberculosis. Finally, much to the relief of 



574 



DISEASES OF CHILDREX. 



the patients and of their relations, the brain also becomes affected, 
coma or delirium supervenes, and the patient soon succumbs. 

At the autopsy I found, in one case, a medullary carcinoma, which 
filled up the whole anterior mediastinum, and extended over the 
anterior part of the right lung, without having occasioned secondary 
nodules in any other organ. In the second case, a cystosarcoma, 
of the size of a large fist, simply compressed, but did not involve 
the lungs and heart. In both, marked hydrothovax, but only slight 
ascites, were present. The dyspnoea of these children, which was 
extremely distressing to themselves, and for others to witness, could 
temporarily be mitigated in a very surprising manner by large doses 
of morphia, gr. | to ^ pro die. 

B.-THE SCROFULOUS CACHEXIA. 
By scrofulosis we understand a series of inflammatory processes 
upon the skin and mucous memhranes, on the organs of sense, sight, 
and hearing, in the lymphatic glands, and on the hones and joints, 
which, anatomo-pathologically, have no connection whatever. They 
differ materially in their course from simple traumatic inflammations 
of these parts, and seldom occur singly, but in most instances on 
several parts of the body at the same time. 

Examination of the affected parts alone, even without taking into 
consideration the entire state of the organism, often furnishes such 
peculiarities that the adjective " scrofulous " may be added to the 
name of the inflammatory process with the utmost surety. This 
remark is especially applicable to some of the diseases of the eye, to 
the ulcerating lymphatic glands, and the affections of the bones and 
joints, while most of the cutaneous eruptions, catarrhs of the mucous 
membranes, and otorrhoea, can only be recognized as being cachec- 
tic by the obstinacy of their course and complication with markedly 
scrofulous affections of other organs. 

The opponents of the scrofulous diathesis theory, who obstinately 
shut their eyes against the manifest common and intimate connec- 
tion between the affections just mentioned, fall back upon this argu- 
ment in particular, that the cachexia has not been shown to he pres- 
ent in the blood. Singularly enough, they forget that, in none of 
the dyscrasife in general, neither in syphilis, nor in carcinoma, nor in 
tuberculosis, has it been possible to detect anything specific in the 
blood ; but that general diseases are here in question has been em- 
phatically acknowledged by all thoughtful physicians. 

The following principles must be maintained from a clinical point 

of view : 

(1.) There are certain chronic inflammations which have an inti- 
mate etiological connection. 



GENERAL DISEASES OF THE SECRETIOXS. 575 

(2.) Children affected by them are, in greater part, the progeny 
of tuberculous parents ; and 

(3.) These children very frequently become tuberculous after the 
appearance of puberty, even when the scrofulous phenomena have 
disappeared long before. 

Scrofula therefore seems to be the commencement— perhaps, also, 
an imperfect development of tuberculosis. According to my ob- 
servations, which, unfortunately, on account of the difficulties attend- 
ing upon the demonstration of tuberculosis in the parents, have 
never led to precise results, it occurs principally in families where 
one of the j^arents is healthy, but the other tuberculous. Where 
both father and mother are tuberculous, most of the children perish 
in the first few years of life, from true tuberculosis, and overleap these 
milder transitions altogether. 

As regards the general symptoms of the so-called scrofulous dia- 
thesis, most of the signs classified under it are merely the simple 
effects of the local processes, and do not depend upon any particular 
inherited anomalies of the constitution. This is also the reason why 
the delineation of the so-called scrofulous habitus cannot be comjorised 
in one picture, but must be given in two forms, the erethitic and the 
torpid. On close examination it is seen that the description of these 
two forms is reduced to extremely vague statements. Thus erethitic 
scrofulous children are said to have a slender frame of body, feeble 
muscular system, keen comprehensive abilities, delicate formation of 
countenance, fine eyes, bluish sclerotica, and dilated pupils. The 
torpid scrofulous diathesis, on the other hand, is said to be recog- 
nized by coarse features, large head, wide jaws, bloated nose and up- 
per lip, reddened eyes, swollen lymphatic glands, and large abdomen. 

In this delineation general constitutional derangements have 
been improperly thrown together with local morbid processes. The 
general characters are extremely unreliable, and in addition entirely 
incorrect ; the local, the bloated nose and upper lip, reddened eye- 
lids, glandular hypertrophies and tympanitic distended abdomen, 
are indeed local phenomena of scrofula, but they are not so constant 
as to be capable of producing the diathesis, and their absence or 
disappearance is by no means proof positive that the children are no 
longer scrofulous. 

Children may, indeed, entirely get rid of their scrofulous habitus, 
of their adenitis meibomiana, of their tumefied nose and upper lip, 
which, in fact, are only caused by chronic catarrh of the nasal mucous 
membrane and its corroding secretion, and, after several months, 
again acquire the same or other scrofulous affections. So, then, the 
habitus will be present, or not, according as to whether these local 
inflammations happen to be present or have disappeared. 



576 DISEASES OF CHILDREX. 

Now, so far as relates to the local processes, they are collectively 
distinguished by a tedious course, frequent relapses, and obstinate 
resistance toward all local treatment by cauterizations, cataplasnis, 
and ointments of all kinds. The majority of them present such char- 
acteristic symptoms that they merit a separate consideration. 

(a.) Ski?i. — Here the discharging eruptions, eczema, impetigo, 
and ecthyma, most frequently occur. 

Furunculosis, which likewise attacks only childi'en of tuberculous 
parents, has already been spoken of on page 536. 

By eczema an inflammation of the skin is understood, in which 
a fluid exudation accumulates beneath the epidermis, and assumes 
the form of small, closely-aggregated vesicles spread over a large 
surface. An eczema simplex and rubrum are distinguished accord- 
ing as the adjoining portions of the skin are strongly or slightly ery- 
thematous and tumefied. The name of eczema impetiginodes has 
been bestowed upon a variety in which the vesicles are larger and 
filled with pus. No particular forms, of course, can be assumed, 
for all the three forms, or, at least, one after the other, may very 
readily occur in one person. 

Symptoms. — In all cases, when the vesicles and pustules burst 
and dry up, yellow scabs form, which are elevated by the succeed- 
ing exudations, and the previous desiccating processes begin anew 
in the same manner. The crusts on the scalp become much 
thicker, by agglutination with the hairs, than on other parts of the 
body. The secretion occasionally becomes so profuse that large 
drops of turbid serum ooze out from some of the existing cracks 
and fissures of the cx'usts, and may even flow down. This exudation 
also corrodes remote parts of the sound skin, and upon these a 
similar suppurating eruj^tion may originate. 

Eczema has no special connection either with the glandular or 
with the follicular apparatus, but is a pure inflammation of the 
cutis ; it is most frequently met with in scrofulous children upon the 
head and face (tinea capitis, porrigo), but, after all, does not wholly 
spare any part of the skin. After from four to eight weeks, a spon- 
taneous recovery usually ensues ; generally, no one place suppurates 
longer than half a year steadily. Where it has existed for more 
than four weeks, the adjacent glands will also be found enlarged, 
especially those of the neck ; for, as has already been remarked, 
eczema most frequently attacks the head. These glandular hyper- 
trophies have the peculiarity of scarcely ever undergoing suppura- 
tion ; but, after the eczema has been cured, gradually lessen in size, 
or remain slightly indurated for some time thereafter. 

Eczema heals without loss of substance ; but, on the hairless 
parts affected, a dai-k discoloration of the skin will remain, which 



GENERAL DISEASES OF THE SECRETIONS, 577 

disappears after several months. Relapses are of frequent occur- 
rence. 

Treatment. — The local treatment only will be discussed here, 
for the general will follow at the conclusion of the section. Ac- 
cording to my thousand-fold observations, simple cleanliness, and, 
for the scalp, the removal of the hair, are entirely adequate to cure 
it. Even this last procedure is not absolutely necessary ; it, how- 
ever, accelerates the desiccation, and is of great benefit to children 
who are extremely annoyed by the agglutinated masses of hair and 
crusts. 

Vain mothers, however, very unwillingly consent to have their 
daughters' hair cut off. It is true that children are much tortured 
during washing and combing of the hair, but it cannot be ignored 
that, even in this irrational, at times even cruel, treatment, a period 
finally arrives when no new exudations take place, and a normal 
skin makes its appearance after the dried scabs have fallen off. 

The crusts ai'e best removed after soaking them with oil ; they 
thereby become soft, and may be taken away without causing any 
pain. [After the crusts have been entirely removed, I order an 
ointment of tannic acid ( 3 j to f J), or of zinc and tar, or of bismuth, 
to be applied. These remedies allay the itching, and prevent the 
reformation of the crusts.] The severe itching of the skin causes 
the patients to scratch themselves incessantly; but this also may be 
prevented to a certain extent by cutting their finger-nails as short 
as possible twice a week. 

By impetigo we understand an inflammation of the skin in which 
small and large pustules spring up on an erythematous base, and 
then dry up into thick yellow or brown scabs. The exudation goes 
on beneath the crusts, elevates them, and for some hours the in- 
flamed corium lies exposed, but soon becomes covered with new 
crusts. The course, the rest of the symptoms, and the local treat- 
ment, differ in no respect from those of eczema. 

By ecthyma and rupia, large solitary pustules are understood, 
which give rise to temporary brown scabs, and then usually mei'ge 
into torpid ulcers. In most instances the inflammatory areolae 
are insignificant, but, when the cachexia is very well pronounced, 
they become bluish red. The ulcers that form after the scabs fall 
off discharge hardly any secretion ; indeed, are almost dry, but 
nevertheless heal very slowly, and frequently last until death. This 
eruption occurs only in emaciated, atrophic children. 

Treatment. — An attempt should be made by the aid of stimulat- 
ing ointments, ung. digestivum, or ung. sabinae, or by lightly pencil- 
ling them with nitrate of silver, to induce a strong reaction in the 
torpid ulcers. The local treatment, however, remains fruitless, if ^ 



578 DISEASES OF CHILDREN. 

no constitutional improvement can be brought about. The remedies 
which are indicated will be prescribed at the conclusion of the sec- 
tion. 

Besides these vesicular and pustular eruptions, the corroding 
tetter, hqms, is yet to be described as being peculiar to scrofulosis. 

Symptoms. — Lupus occurs in children under all the four forms 
which dermatology teaches. We have (1) a X. exfoliata, (2) i. 
tuberosa, (3) X. exidcerans, and (4) L. serjnginosus, or ambulans. 

Lupus exfoliatus consists in large and small hypertrophied spots 
on the integument, having glistening ground-off upper surfaces, 
which constantly desquamate, and induce an intolerable itching. In 
color, these hypertrophied spots vary from a rosy to a bluish red. 
The induration is more marked than the projection above the level 
of the normal skin. 

Lupus tuberosus differs from the first form only by the greater 
prominence of the tubercles, which, by aggregation, may swell up 
into large, bluish-red tumors, and sometimes feel hard, but some- 
times also fluctuate. The desquamation and color are the same in 
character as in the first. 

Lupus exulcerans, also called phagedsenicus, seldom originates 
primarily as such, but generally develops itself from one of the forms 
just mentioned. It is characterized by hard cutaneous exudations, 
which rapidly liquefy, and leave behind deep, uneven ulcers. These 
ulcers discharge no pus, but a brownish ichor, and heal extremely 
slowly. They penetrate into the deeper structures, and do not spare 
even the bones. The crusts which, by the diminution of the dis- 
charge, form from time to time, are usually soon cast off. 

Lastly, lupus serpiginosus is distinguished by the formation of 
deeper ulcers, which constantly become larger and larger by the dis- 
integration of the new exudation deposited in the edges of the ulcer, 
while the parts first attacked contract, become flat, and assume a 
healing action. The cicatrices always remain white, depressed, and 
corrugated, and the loss of substance, especially when the lupus was 
located on the nose or eyelids, is very disfiguring. 

None of these four forms ever occur in the healthy, but only in 
the cachectic, and, in fact, chiefly in well-pronounced scrofulous, 
less frequently in syphilitic children. Their site is preferably in the 
face, most frequently on the nose, next on the cheeks and lips, very 
rarely on the trunk and extremities. 

The course is very chronic, and, in most instances, it takes years 
to cure them ; the loss of substance is always considerable, and the 
cicatrices are visible all through life. 

Treatment. — The local treatment of lu'iius, especially the corrod- 
ing form, is of great importance. It is absolutely necessary to put 



GENERAL DISEASES OF THE SECRETIONS. 579 

a stop to the progress of the evil by a systematic course of cauteriza- 
tions. Nitrate of silver is not powerful enough for these cases, and 
we have to resort to arsenic or chloride of zinc paste. DupuytrerCs 
arsenic powder (ninety-eight or ninety-nine parts of calomel and one 
or two parts of white arsenic) is especially adapted for superficial 
cauterizations, when not too near the mouth and nasal passages. 
The ulcer should be cleansed, and the powder applied one-third or 
one-half a line in thickness, over which a layer of gum-arabic pow- 
der should be spread ; the moisture of the ulcer soon converts the 
whole into an adherent paste. After from eight to ten days the 
paste falls off, but, in most instances, has to be reapplied several times. 

Chloride of zinc paste is less dangerous on account of possible 
poisoning, and none the less efficacious. One part of chloride of zinc 
is mixed with two or three of starch-powder, stirred up with 
a few drops of water, and then applied upon the cleansed ulcer. 
The chloi'ide of zinc corrodes to a depth equal to the thickness of 
the layer. The cauterization has to be renewed, after the eschar 
falls off, until a fine, granulating surface appears. 

Thiersch has had remarkable success in the treatment of lupus 
with a solution of acetate of alumina, diluted so as to cause but little 
pain. The solution is applied with charpie, and retained in place by 
a bandage. Lately the treatment of lupus has been greatly modi- 
fied by the use of the curette, which seems to render escharotics en- 
tirely unnecessary. 

I have seen excellent results from phosphorus administered in- 
ternally, dissolved in oil or ether, in the treatment of lupus. 

Without an internal treatment with cod-liver oil, continued for 
years, not even temporary relief will be attained by the most j^ower- 
ful escharotics. It is hardly necessary to state that it is not practi- 
cable to apply the chloride of zinc paste without anaesthetizing 
the little patient. 

(b.) Mucous Menibranes and Orrjans of Seiise. — The morbid 
alterations of the organs of sense, with those of the mucous mem- 
branes, generally are treated together, because in scrofulous affec- 
tions the organs of vision and hearing invariably particijaate in great 
degree with their mucous membranes. 

The mucous membrane of the mouth and alimentary canal dis- 
plays no characteristic scrofulous affections. Bronchial catarrh, so 
frequent and tedious in scrofulous children, are much more probably 
produced by actual tuberculosis of the lungs than by scrofula. Like- 
wise in the uropoetic system no particular derangements occur ; in 
the vagina, however, a tedious Icucorrhccais often observed in scrofu- 
lous girls, a more detailed description of which has already been 
given on page 404. 



580 DISEASES OF CHILDREN. 

Marked scrofulous lesions occur only on tbe mucous membrane 
of tbe nose, of tbe eye, and of tbe ear. 

NOSE. 

A suppurating eruption, eczema, or impetigo, very frequently at- 
tacks tbe nasal cavities at tbe place of transition from tbe mucous 
membrane into tbe cutis, in consequence of wbicb tbe former be- 
comes bypertropbied, and discbarges a large quantity of corroding 
secretion. Tbe nasal cavities are finally totally occluded by tbe 
crusts, wbicb constantly become thicker and tbicker ; tbe tip of tbe 
nose swells up, and tbe acrid secretion tbat flows down over tbe 
upper lip produces a cbronic inflammation and infiltration of tbe 
integument of tbese parts. Tbe tumidity of tbe nose and upper lip 
is of sucb frequent occurrence tbat tbe scrofulous diathesis is usu- 
ally diagnosticated by it. 

Altbouorb it cannot be denied tbat children so constituted are 
always scrofulous and suffer from still other scrofulous affections, 
nevertheless it does not follow that those who have no swollen nose 
and upper lip are not scrofulous too. Tbis affection is by no means 
so frequent that it might be identified with the scrofulous diathesis. 

Tbe recovery requires months, and even years, and, when the 
eruption has finally disappeared, the infiltration of the cutis yet re- 
mains for a long time. Tbese simple eczemas have nothing in com- 
mon with lupus, polypous growths, and purulent coryza, or ozaena, 
nor do they generally merge into such conditions. 

Scrofulous ozoena consists of a bloody, purulent discbarge from 
one or both nares, and is distinguished from the affections of the 
mucous membrane just described by tbe never-absent pungent smell 
of the matter that flows from the nose. It is also very tedious, dis- 
appears sometimes for several weeks, and then returns with its 
former severity. In most instances a periostitis of a part of the 
nasal bones is at the bottom of this complaint, and small necrosed 
pieces of bone are also occasionally discharged. This sufficiently 
explains the intense odor and the protracted course. 

Treatment. — Injections of cold water or weak astringents render 
essential service when tbe children become large and sensible. In 
small children, who obstinately resist these measures, we have to be 
content with the use of a weak ointment of red precipitate (gr. iij 
to lard 3 j), introduced into tbe nose by the aid of a thin bourdon- 
net. Here, also, tbe general treatment is tbe principal considera- 
tion. 

EYE. 

The Meibomian glands on the lids very frequently ulcerate. 
Many hordeola form, part of which pass over into suppuration, and 



GENERAL DISEASES OF THE SECRETIONS. 55 1 

part into induration. The adjacent parts of the eyelid are here 
swollen, and quickly become excoriated in consequence of the accu- 
mulated augmented secretion. This affection likewise lasts several 
months, and often terminates with total or partial loss of the cilise. 
Most frequently, however, the dyscrasia becomes located upon the 
conjunctiva bulbi. 

In conjunctivitis scrofulosa, phlyctenulge almost always occur 
upon the sclerotic conjunctiva. They are flat, yellowish-white ele- 
vations, from a pin's head to a lentil in size, surrounded by an 
agglomeration of dark-red blood-vessels. The bulk of the vessels 
generally runs from the angle of the eye like a skein of thread toward 
the phlyctenulge. I look upon them as being probably miliary tu- 
bercles of the conjunctiva, because they occur only in scrofulous 
children. I have never yet had an opportunity of excising any 
phlyctenule in the living child and subjecting them to a microscop- 
ical examination, in which manner only the question can be decided. 

After several days these phlyctenulae burst, the vessels running 
to them atrophy, and soon disappear altogether. When this process 
is completed, no permanent injury to the eye, nor any visible residue, 
is to be observed. But the case is entirely different where the cor- 
nea has been affected. 

Keratitis scrofulosa presents itself either as a simple further de- 
velopment of the vessels of the sclerotic conjunctiva upon the cor- 
nea, so that radiating vessels run to it at one point, or around its 
whole periphery, or large or small ulcers form at some one point on 
the cornea. 

These corneal ulcers likewise originate from pustules, which cor- 
respond to the phlyctenulaB of the sclerotic ; here, however, they 
burst uncommonly quickly, and, in a short time from the commence- 
ment of the evil, no pustules are to be seen on the cornea, but, instead, 
a small, visible, shallow depression, the result of a loss of substance, 
around which the cornea appears hazy or of a milky opacity. The 
ulcers thus originated, of which several often aj^pear at once, require 
a long time to heal up. The place where they were situated often 
looks as if ground off, but the smoky opacity of the base of the 
ulcer and its vicinity does not disappear for many years, or remains 
visible all through life — macula cornea. 

In strongly cachectic individuals, the ulcers may penetrate deeper 
and deeper, and finally perforate the cornea. If the ulcer was situ- 
ated centrally, so that the perforation, after the escape of the water 
from the anterior chamber of the eye, could not be closed up by the 
iris, phthisis bulbi generally ensues. But if the ulcer was situated 
more peripherally, then the iris prolapses, becomes covered with 
exudation, and the patients recover with a deformed pupil, by which 
38 



582 DISEASES OF CHILDREN. 

the power of vision is but little diminished. At the place of union 
between the iris and cornea, a white spot with a black central point 
forms, from which a staphyloma may subsequently develop itself. 

Perforation by the scrofulous ulcers seldom occurs ; on the whole, 
hardly one out of a hundred perforates, and, of those which do, the 
favorable termination of prolapsus of the iris occurs comparatively 
often. 

Blepharospas^nus, spasm of the lids, is very characteristic of 
scrofulous inflammation of the eye. It is produced by the great 
intolerance of light, which is absent in a small number of cases only. 
Children will not open the afflicted eye throughout the whole day ; 
during daylight they hide themselves in dark corners and rooms, 
keep their hands before the face, and hinder as much as possible the 
penetration of light into the eye. Although it must be acknowl- 
•edged that complaisant, obedient children, after much persuasion, 
are finally induced to open their eyes for a moment, or at least sub- 
mit to have them opened, nevertheless, in other cases, the penetrat- 
ing light produces such violent irritation that the child, wnth the 
utmost desire to open its eyes, is unable to do it. Such a child may 
indeed be secured by assistants, and the lids forcibly torn apart by 
the hands, but some bleeding from the angles of the eye and swell- 
ing of the lids are always produced thereby. 

Therapeutically, this violent tearing ojjen of the lids is of no use 
whatever, for the treatment remains the same whether there are any 
ulcers or not ; a palpable barm, however, may result from the 
marked swelling and unavoidable bruising of the lids. In regard 
to the prognosis, this procedure may be of more importance ; for a 
perfectly favorable prognosis may be given to the profoundly 
afflicted parents, when none or only a peripheral ulcer of the cornea 
can be discovered. 

The intolerance of light is not always in exact relation to the 
material alteration of the cornea ; the former is often present to a 
high degree, and the latter structure entirely intact. Along with 
the intolerance of light there is always profuse lachrymation, and 
the tears, in common with the friction and constant pinching of the 
eyelids, the result of violent contraction of the orbicular muscle, soon 
produce a humid vesicular eruption of the whole moiety of the face. 

Scrofulous inflammations of the eye relapse extremely often — 
it may almost be said, invariably. It takes at least half a year — 
often, however, many years — before the subjects attain to such a 
condition as to properly enjoy life again. The violent, continuous 
pains, by which these affections are accompanied, usually produce 
also some fever and loss of appetite, upon which a visible emaciation 
of the whole body supervenes. 



GENERAL DISEASES OF THE SECRETIONS. 583 

There is a very peculiar alteration of the cilise in chronic scrofu- 
lous inflammations. At first they grow to a singular length and 
thickness, but thereby lose their plain, arch-like curve, and become 
undulating, almost curled. Later, all these degenerated eyelashes 
fall out, and are replaced by fine, small, sparsely distributed hairs, 
which remain for life. 

The alternating character of the different local manifestations of 
the cachexia is seen most distinctly in scrofulous ophthalmia. The 
corneal ulcerations may persist for many months, and constantly 
grow worse in spite of all local and general treatment, when, sud- 
denly, an eczema attacks the head, or an otorrhoea, or a bronchitis, 
or a scrofulous affection of the bones, supervenes, and the obstinate 
inflammation of the eyes is completely gone in a few days. Intol- 
erance of light, lachrymation, and vascular injections, have vanished, 
as if by magic, nothing but an opacity of the cornea remains, which, 
with the exception of producing a diminution of the power of vision, 
has no further bad effects. 

Treatment, — Notwithstanding all rational and irrational, painful 
and painless, old and new remedies, which ophthalmologists have 
recommended in large numbers, there is still no method of treat- 
ment which notably exercises an aborting and mitigating effect 
upon the course of this pertinacious evil. 

The eyes should not be allowed to be bandaged ; a green shade, 
however, is beneficial. All ointments and collyria are, so long as 
redness and pain exist, injurious, and increase the irritation. There 
is nothing better for this inflammatory stage than tepid-warm, dis- 
tilled water, with which the eye may be bathed and irrigated every 
hour. Cold applications, in most cases, aggravate the pains and 
redness. 

The patients should not be encouraged in their efforts to entirely 
avoid the light. They should be provided with a plain shade — um- 
braculum — and be confined in a darkened room. Some benefit is 
derived from instilling into the eye a drop or two of a concentrated 
solution of atropine (gr. j to water 3 ij) several times daily, and 
from the internal use of the extract of belladonna, of Avhich gr. ss. 
may be given in the twenty-four hours. Immersions of the head in 
cold water have a decidedly beneficial effect upon the blepharospas- 
mus ; it is, however, but a few hours in duration. These proced- 
ures can only be executed under the violent struggles of the chil- 
dren and their parents ; and the usual consequences are, that the 
former are not to be found when the time comes for the next im- 
mersions. I have therefore given up this somewhat brutal treat- 
ment for the last few years, and I think the results have been quite 
as favorable. 



584 DISEASES OF CHILDREN. 

When the patients are not intensely tainted with tuberculosis, 
Avhich is not the case, as a rule, they will tolerate inunctions of blue 
ointment very well, and a tolerably good, although not always more 
rapid course, is observed from this treatment. 3 ss. — 3 j of blue oint- 
ment is rubbed in upon the forehead daily, over which a broad 
bandage must be tied, for otherwise the children will smear them- 
selves all over with it, and the ophthalmia becomes aggravated if 
any of the ointment gets into the eye. 

Against severe pain, sleeplessness, and general excitability, mor- 
phine will always prove to be the sovereign remedy. I generally 
cause gr. ss. to be dissolved in 3 iij of water, and of this solution 
give half-teaspoonful doses, according to necessity. No bad con- 
secutive effects can be perceived from such small doses of morphine ; 
leeches, which formerly were often resorted to, likewise, on account 
of their pain-assuaging effects, may, however, cause much harm 
through consecutive anaemia. 

[A much more efficient remedy for the subjugation of the spasm 
of the orbicularis muscle, in blepharitis, is the hydrochlorate of 
cocaine. It is even still more useful for the relief of pain in the 
scrofulous keratitis, spoken of above, and in the keratitis and con- 
junctivitis, described on page 78, and in otitis interna, page 36G.] 

When the course is an obstinate one, and no cutaneous erup- 
tions are present, a rapid, remarkable improvement of the affection 
of the eyes may occasionally be seen from the production of pustules 
by tartar-emetic ointment. Autem'ietJi's'^ ointment, however, is a 
totally inappropriate preparation for the purpose of attaining this 
end. The patients scratch the places where the ointment has been 
applied, and then rub their eyes with the soiled fingers, by which 
they palpably aggravate tlieir ophthalmia. For a number of years 
back I have been in the habit of applying to the nape of the neck 
a mixture of one part of tartar, stibiat. and three parts of emplas. 
citrin., smeared upon strips of adhesive plaster to the thickness of 
the back of a knife. At the end of four days the plaster may be 
removed, when a number of pustules will be found to have formed, 
which may be kept in a state of suppuration for a long time by the 
use of ung. sabinae. 

Against the blepharitis and adenitis meibomiana, desiccating or 
slightly stimulating ointment may be resorted to. Here the white 
precipitate (gr. ij — iv to adepis 3 j) and ung. zinci are especially 
serviceable. 

As has already been observed, all these remedies have no de- 
cided effect, and the principal procedure is always a year's continued, 
circumspect, general treatment. 

* [Ung. antim. et potas. tart.] 



GENERAL DISEASES OF THE SECRETIONS. 585 

EAR. 

Scrofula furnishes the chief cause for affections of the ear, es- 
pecially chronic otorrhoeas, the termination of otitis externa and in- 
terna. Diseases of the bones of the meatus auditorius, and of the 
petrous portion of the temporal bone, occur almost altogether in chil- 
dren of tuberculous parents, and are combined or alternate with other 
local affections of the cachexia. The morbid conditions belonging 
here have already been delineated in detail on pages 362 to 368. 

(c.) Lymphatic Glands and Subcutaneous Cellular Tissue. — 
Swellings of the glands are of extremely frequent occurrence in scrofu- 
lous children, in most instances produced by adjacent affections of the 
mucous membrane, or of the integument. The lymphatic glands of 
the neck swell up most frequently ; those of the axilla and groin not 
quite as often. 

Pathologically, a distinction may be made between simple hyper- 
trophy and tuberculosis of the lymphatic glands ; practically, however, 
no such distinction can be maintained. One may often see that a 
child becomes affected with glandular swellings in the neck in conse- 
quence of an eczema of the head, and that these glands, which origi- 
nally were simply hypertrophic, Bevertheless, after the eczema has 
long been cured, pass over into suppuration, and become tubercu- 
lous. It is scarcely possible to separate the scrofulous from the tu- 
berculous glands, for the transition of the former into the latter occurs 
gradually, and does not manifest itself by any precise symptoms. 

Pathological Anatomy. — Numerous extirpations of hypertrophied 
glands, and multiplied post-mortem appearances, have shown that 
simply hypertrophied and tuberculous infiltrated glands may occur in 
the same person. 

In the simply hypertrophied glands there is but a slight alteration 
of structure. The longer they have existed, all the firmer and denser 
becomes the substance. The superficial surface, in most instances, is 
very vascular ; when cut into and compressed, a turbid fluid may be 
squeezed out, which, under the microscope, exhibits the characteristic 
glandular element, numerous granules, a few cells, and some connec- 
tive-tissue fibres. Occasionally smaller and larger cavities, with clear 
contents, occur scattered throughout the parenchyma of the gland. 

The tuberculous glands are always at the same time enlarged, 
And, on section, display either small hyaline, gray miliary tubercles, 
or large yellow tubercles, and aggregations of tubercles. In the se- 
verest form of the evil almost the entire glandulai parenchyma -will 
disappear, and be supplanted by a tuberculous mass. Suppuration is 
the usual termination of tuberculous glands; calcification seems to 



586 DISEASES OF CHILDREN. 

occur but very rarely in cliildren. As the softening' progresses, the 
parenchyma and adjacent celluhir tissue become inflamed, abscesses 
form, and finally the well-known, slowly-heaUng fistulous tracts and 
undermining ulcers result. 

Symptoms. — Tuberculous glands are most frequently situated on 
the neck, and a single gland alone hardly ever becomes aifected ; 
large convolutions, as a rule, may be felt on both sides of the neck, 
under the chin, and behind and beneath the ear. When the glands 
become enlarged very slowly and without any pain, they usually re- 
main tolerably movable ; in the contrary case, and particularly when 
they pass over into suppuration, they become tense and immovable. 
A lively pain, increased on pressure, then comes on in all cases, the 
integument constantly grows redder and thinner, finally breaks, and 
a flocculent, thin pus escapes, with which large tubercular granules 
are occasionally expelled. Generally several glands break open at 
one time, or soon after each other, at dificrent places, and the suppura- 
tion is always extremely tedious. Very j^eculiar ulcers, wdth callous, 
extuberating edges and lardaceous bases, now form, from which irregu- 
lar portions of the gland protrude. 

Finally, after several months, the callous edges soften, the ulcers 
become clean and heal up, but not without the formation of disfiguring 
cicatrices. It is a remarkable fact that the general state of the sys- 
tem does not suffer here at all ; the children look blooming, and thrive 
excellently well, provided the tuberculosis remains confined to the 
glands, and does not simultaneously attack the lungs, or some other 
vital organ. The course, aside from the disfiguring cicatrices, is, in 
the majority of cases, favorable ; and usually, when the ulcers have 
Dnce completely healed up, no new swellings and suppurations ensue. 

As regards the complications, according to Leherffs famous re- 
searches, scrofulous ophthalmia precedes or becomes superadded in 
seven-sixteenths of all the patients, two-fifths of the cases become 
complicated with diseases of the bones, one-fourth with cutaneous 
affections, one-fourth likewise with diseases of the joints, and one-sixth 
with superficial ulcers and abscesses. According to the observations 
of the same author, tuberculosis of the glands is very rare between 
the first and fifth year of life, i. e., one-twelfth of its cases, more fre- 
quent between the fifth and tenth year, rate one-fifth ; most fre- 
quent between the tenth and fifteenth year, viz., almost one-third 
of all its cases. From the fifteenth to the twentieth the frequency is 
still considerable, i. e., two-sevenths. From that time on, the disease 
becomes more rare ; for, after that age, tuberculosis more firequently 
attacks the lungs than the lymphatic glands. 

Tuberculosis of the lymphatic glands is of itself devoid of danger, 



GENERAL DISEASES OF THE SECRETIONS. 587 

but very generally tuberciolosis of tlie lungs comes on after puberty, 
and prognostically, therefore, this danger must always be kept in 
view. 

Treatment. — In the simple and inflammatory hypertrophy of the 
glands, the cause is, above all, to be taken into consideration. The 
glands never grow smaller so long as the scrofulous affection of the 
skin or mucous membrane, that has produced it, still continues. Not 
till after these have been cured, and the glandular hypertrophy does 
not disappear, may the effort be made to remove it by the local ap- 
pKcation of tincture of iodine twice or thrice weekly. Simple swell- 
ing of the glands disappears under such a use of iodine continued for 
some time, but tuberculous very quickly thereby become inflamed 
and come to suppuration more quickly. Still, this last process need not 
be looked upon as an unfavorable occurrence, because the tuberculous 
masses cannot be absorbed, and are really eliminated from the system 
in this manner. 

The tuberculous softening at times goes on surprisingly slowly ; 
it scarcely ever, however, fails to take place, for calcification rarely 
occurs in childhood. All cutaneous irritants seem to accelerate it, and 
it is therefore rational to employ them. Here belong all the salves 
and plasters which make the skin red and inflamed, and a large number 
of which are current as popular remedies. 

The ulcers that have already broken are to be treated according to 
the generally-adopted rules of surgery. When the healing is pro- 
tracted for too long a time, a marked progress may be perceived from 
the use of red-precipitate ointment. Against simjple induration, iodine 
will alwaj^s prove a sovereign remedy. The greatest caution, how- 
ever, must be exercised, in its internal use, for the always-to-be-sus- 
pected pulmonary tuberculosis occasionally makes visible progress 
thereby. Mineral waters containing iodine and bromine are best 
adapted for long use. HypertropHed glands may soon be reduced 
in size by the continuous local use of tincture of iodine ; it will, how- 
ever, very seldom be possible to remove them altogether. 

Extirpation of glands can only come into consideration when the 
inflammatory phenomena have long ago disappeared, and only a 
few glands have remained hypertrophied. In the contrary case, the 
wound of the operation, instead of healing up, may be expected to 
assume the character of a glandular ulcer, with the well-known callous 
edges. 

(d.) Dones, Inflamm,atio7i of the Periosteum [Periostitis Serofu- 
losa). — Inflammation of the periosteum is not infi-equently the mani- 
festation of scrofula or local phenomena of other remote affections, and 
occurs either as an acute inflammation or has a chronic insidious ani] 



588 DISEASES OF CHILDREN. 

sometimes a very destructive termination. In rare instances a trans- 
formation of the primitive chronic into an acute periostitis may be ob- 
served. 

The disease extends over a larger or smaller part of the bone ; 
sometimes it attacks the periosteum of the bone in its entire circum- 
ference. Its site is generally on the long tubular bones of the ex- 
tremities (tibia, femur, and humerus) and other compact bones ; 
spongy bones are seldom affected. 

The pathological character of acute periostitis, which occurs as 
often as the chronic, is distinguished by an acute injection of the 
periosteum, mostly in the form of a uniform redness and by a swollen, 
flocculent, and spongy appearance ; later on, the periosteum is bathed in 
a muculent, tenacious, shreddy fluid exudation, and can be easily peeled 
off. In the insidiously-appearing periostitis, the hyperasmia is less in- 
tense, more in the form of a striped or spotted redness ; the periosteum 
changes to a lardaceous, grayish-red, or grayish-white mass, which is 
less easy to pull off from the bone and adjacent soft parts. When the 
disease has existed for some time, the latter as well as the periosteum 
will frequently contain small spiculie or lamellae of newly-formed osseous 
substance ; these are always apt to form whenever the periostitis is of 
some duration. 

The additional alterations which the inflamed periosteum under- 
goes in scrofulous children are as follows : 

Complete resolution and retrogression to normal texture are extreme- 
ly rare ; a permanent hypertrophy and increase in bulk, with organiza- 
tion of the inflammatory product into soHd tissue, occur somewhat 
more frequently, though on the whole Ukewise rarely ; the termination 
in suppuration or sanies is predominantly frequent. In the latter 
processes pus forms in the inflamed periosteum as well as in the ad- 
jacent soft parts, which, uniting with the purulent collections in the 
bone, may form one large purulent reservoir. If the pus breaks out- 
wardly and the periostitis was limited to a small, circumscribed spot, 
healing and cicatrization may indeed ensue, still these are very rare oc- 
currences ; the periosteum, as a rule, is undermined to a great extent, 
and separated from the bone ; the latter is thus deprived of its nutri- 
tive conditions necessary for its existence, and the next effect is necrosis. 
In other cases, and when the influence of the scrofulosis continues, the 
suppuration assumes the character of ichorous liquefaction, which also 
extends to the subjacent bone, and induces in it the same process — 
caries (S. caries and necrosis). 

Scrofulous periostitis less frequently indicates tuberculosis than 
scrofulous ostitis, for tuberculous masses often appear as the inflam- 
matory product of the last. The symptoms of scrofulous periostitis 



GENERAL DISEASES OF THE SECRETIONS. 589 

are in general those of ordinary periostitis, and differ according as to 
whether the course is acute or chronic. In most cases there is at first 
a local, not distinctly-defined pain, diffused along the length of the 
bone ; it has a peculiar dull character, and is aggravated on pressure. 
Soon the pain, which at the commencement was only transient, becomes 
more constant and severe, particularly in bad states of the weather, 
frequently also at night. The affiicted Hmb swells faster or slower ac- 
cording to the character of the inflammation, the skin becomes tensely 
stretched, and can no longer be raised in folds ; in the first stages the 
tumefaction is hard and dense ; when suppuration ensues, one or more 
soft places will be found, then distinct fluctviation, and finally the 
abscess breaks, after the cutis has become bluish red in color and the 
epidermis elevated. Spongy granulations, which bleed at the slight- 
est touch, exuberate from the openings, which often rapidly become 
enlarged. The pus that escapes difi"ers in character according to the 
depth the processes run (caries or necrosis). 

The general condition of the system, in the chronic course, is often 
but little affected, if it is not disturbed at the same time by other re- 
mote scrofulous diseases ; on the other hand, in the acute as well as 
in suppurative stages it is always attacked by febrile phenomena, 
which may attain to hectic fever in the case of extensive profuse sup- 
puration and weakness of the individual, which are frequently present. 
It terminates with the destruction of the patient. 

According to the described symptomatology, it will not be espe- 
cially difficult to form the diagnosis. 

The prognosis must be put down as unfavorable, on account of the 
caries or necrosis which so frequently follows. The periostitis, even 
before these processes have distinctly developed themselves, may 
endanger the life of the patient by profuse suppuration. 

Therapeutics. — The treatment, at the commencement, should be 
with resolvents, although these will bring about the desired effect in 
the smallest number of cases only ; in addition to these, pain-assuaging 
remedies (internally and externally) must be employed, combined with 
absolute rest of the afflicted limb. Cataplasms, as a rule, relieve the 
pain very quickly, and for a long time, especially in commencing sup- 
puration ; but, as soon as that is clearly ascertained, the abscess should 
be punctured, for, if it is delayed, the rapid accumulation of matter 
will extensively separate the periosteum from the bone, and large por- 
tions of it will be destroyed in most instances. 

Inflammation of the Medulla of the Bones ( Osteomyelitis — JiJn- 
dostitis). — Inflammation within the medullary canal of the tubular 
bones occurs tolerably frequently in scrofulous persons. The anatomo- 
pathological conditions of this affection are : hyperasmia, with dark-red 



590 DISEASES OF CHILDREN. 

discoloration of the marrow, conjointly with which small extravasa- 
tions of blood now and then also occur, followed bj suppuration, 
at first at small scattered places, which spread more and more, while 
the hypersemia subsides. The medulla retains a dirty, brownish-red 
color, and liquefies ; the bony walls are seen either discolored, per- 
vaded by granulations and ichor, undergoing absorption, and be- 
coming carious, or, when the suppuration of the medulla increases 
raj)idly, they are seen to lose their supply of blood, and to be attacked 
by necrosis (caries and necrosis centralis). After a while the affection 
may attack the bone in its whole thickness, implicate the periosteum, 
and induce the same processes, which will be described in detail in 
the inflammation of the osseous structure and its terminations. The 
symptomatology and therapeutics are also almost identical with those 
of that aifection. 

That form of inflammation of the marrow appearing in scrofulous 
subjects, in which the contents of the medullary spaces, and the can- 
cellous structure of tubular bones, especially those of the hand and 
foot, appear inflamed, is of more frequent occurrence than the above ; 
inflammation of the periosteum is always present with it. The pro- 
cess, which in its subsequent stages is known as osteoporosis, 
osteospongiosis, spina ventosa, is of such a character in the first 
periods that all the osseous cancelli, and the medullary cavities, are 
found filled with dark-red, bloody fluid, rich in cells, sometimes 
even with purulent degenerated marrow, while the periosteum is 
seen nypergemic and swollen. At a further stage of the evil, puru- 
lent dissolution and absorption of the osseous substance take place 
within the bone tlu-ough the inflammatory action, by which the can- 
celli attain to abnormally large size, while, externally, irregularly, thin 
bony lamellae form, from the similarly-inflamed periosteum, and, in 
part, are again destroyed by the process of absorption which goes on 
from within. In this manner the bone may increase in bulk enor- 
mously, while its substance has, nevertheless, become diminished, for 
its internal part consists of very large, coarse meshes, large cavities, 
or irregular cells, very much as if the bone has been strongly inflated 
(therefore, also, the name spina ventosa). In the developed state of 
the afi'ection, it is impossible to distinguish the cancellous structure 
from the medullary cavities. 

The afi'ection frequently occurs, in scrofulous children, on the hands 
and feet, and generally on the metacarpal and metatarsal bones, or 
the phalanges, which often become expanded and misshaped, and pre- 
sent bulbous or globular swellings (similar to the enchondroma on 
the fingers, which the process under consideration also resembles in this 
respect : that in it, as a rule, the joints remain free or unafi'ected). 



GENERAL DISEASES OF THE SECRETIONS. 591 

The process often does not attain to suppuration, but, when it does, 
numerous fistulous openings will form ; most of them, however, remain 
small. 

Therapeutics. — By the use of proper remedies, directed against the 
fundamental disease, in addition, by bathing the afflicted hmb (either 
with tepid or alkalescent water), and by a compressive bandage, ap- 
phed for a long time, a cvu-e may not infrequently be performed with 
but slight deformity. 

Inflammation of the Bony Structure ( Ostitis Serofidosa) . — In- 
flammation of the osseous tissue frequently occurs in scrofulous chil- 
dren, and has its site cliiefly in the spongy bone-tissues (in the irregu- 
lar and short bones of the extremities, in the epiphyses of the long 
bones, the vertebrge, etc.) ; still, it also occurs in the flat, compact, and 
tubular bones ; in fact, no bone of the skeleton is excepted. 

An inflammatory nucleus forms at some part of the bony structure, 
which quickly gains ground, or several originate, and then become con- 
fluent, under more or less marked hypergemia, which may attain to actual 
extravasations of blood. The cancelli of the bone are superabundantly 
filled with an oleagino-gelatinous fluid, which is soon supplanted by 
granulations, displaying a profuse quantity of cellular structure ; the 
cancelli of the bony-tissue become larger as the granulations produce 
an absorption of the osseous tissue (osteoporosis). The bone itself, 
at the inflamed place, appears larger in bulk, although its structure 
has not increased, but, on the contrary, become diminished. This 
condition becomes particularly apparent when the inflammation is 
situated near the superficial surface of the bone. Abscesses are also 
often seen to form in the adjacent soft parts, even when the inflam- 
mation is situated in the depth of the bone, and does not involve its 
superficial surface. 

In scrofulous subjects the tuberculous inflammation, which attacks 
especially the spong}'^ bones and epiphyses, is the form which most 
frequently occurs. Accompanied by hypereemia, one or several nuclei, 
of a globular form, or a uniform infiltration of the osseous substance, 
with a semi-transparent, yellowish-gray, gelatiniform exudation, takes 
place. When there are only a few scattered nuclei, some of them 
wiU be sin-rounded by a sort of envelope, which likewise euAvraps the 
exudation, but it disappears in the progress of the lesion. Softening 
soon takes place, the several aggregations turn to a yellowish color, 
a crumbling, cheesy matter is seen in the thick, pultaceous fluid, and, 
when the process goes on faster, and is more extensive, small frag- 
ments of bone will not infrequently be found. By this process cavi- 
ties form in the bone, which, by constant extension and approxima- 



592 DISEASES OF CHILDREN. 

tion, will finally unite into considerable-sized caverns ; the bone be- 
comes rotten, and crumbles down, as it were, within itself. In the first 
stage, recovery may take place by the fluid contents of the nodes becom- 
ing absorbed, and these undergoing calcification, while the bony tissue 
near them becomes condensed ; but the breaking of the abscess, and 
evacuation of the tuberculous matter, with a continuation of the pro- 
cess as tuberculous caries, which then passes through its various me- 
tamorphoses, are of more frequent occurrence (S. caries). 

Tuberculous infiltration attacks either a whole bone or a part of it 
— a vertebra, for example — in this manner : a bone is pervaded by the 
yellowish-gray inflammatory product, and a number of yellow streaks 
and spots soon appear, which rapidly become enlarged, coalesce, and 
consist of purulent fluid, intermixed wdth crumbling granules, which 
quickly assume the character of a puriform ichor or sanies. Under 
its influence the bony tissue soon breaks down into small or large 
particles, which are sometimes found in the ichorous fluid that is dis- 
charged. If the process goes on still further, it may next also in- 
volve the periosteum, destroy it, and cause death and exfoliation of 
the bone. In other, rarer instances the disease becomes arrested after 
the exfoliation of the infiltrated parts, and a recovery takes place by 
the cancelli becoming filled up with granulations W'hich spring up from 
the still healthy adjacent part of the bone, or from the periosteum 
and its vicinity. The terininations of inflammation of the bony sub- 
stance, after it has existed as such for a longer or shorter period, are : 

(1.) Resolution. Complete resolution is an exceedingly rare oc- 
currence in scrofulous persons, and is only observed in inflammations 
imj^licating small portions of a bone. 

(2.) Suppuration^ with subsequent healing without transition into 
caries. The transition into suppuration occurs tolerably often ; a 
cure, however, is rarely effected after the breaking and evacuation 
of the abscess have taken place ; in most cases purulent infiltra- 
tion and protracted caries then follow. In this termination the can- 
celli are distended, enlarged, and full of pus, and, as the bony substance 
breaks down, larger or smaller cavities form — a process which may 
go so far that finally but one cavity is to be found, extending through- 
out the whole bone, having only a thin osseous shell, which constantly 
grows still thinner, covered by periosteum — abscess of the bone. If 
the matter has tunnelled its Avay into the soft parts, it may then either 
break through, especially if abscesses preceded by inflammation have 
already formed in these, either in a straight direction, corresponding 
to the site of the afifection, or it may travel on for a distance between 
them, and appear at a greater or lesser distance from the original 



GENERAL DISEASES OF THE SECRETIONS. 593 

place. The pus is yellow or yellowish white, devoid of anj Dad odor, 
in most instances somewhat tliin, and has no corroding properties 
(it is said to contain a larger quantity of phosphate of lime — j^Iq- to 
y^-g — than pus formed in soft parts — 3^0^). The pus continues to be 
discharged for some time, and when, in favorable instances, it ceases, 
the orifice will close, and the cavity becomes filled with granulation, 
in which, in the course of time, ossification takes place. 

(3.) Caries. 

(4.) JVecrosis. 

Both these terminations of inflammation present such noteworthy 
peculiarities that they have to be considered separately. The syinp' 
toras of ostitis vary according to its site and extent, and as to 
whether the soft parts are implicated in the inflammatory process or 
not. Pains are never absent. Sometimes they are stationary, and 
then again migratory and radiating. 

The tumefaction of the affected parts also varies, and, as a rule, it 
is difficult to decide how much is due to the oedema of the soft parts, 
and how much to the hj^pertrophy of the bone and periosteum. The 
integument is mostly very sensitive and inflamed, particularly when 
abscesses threaten to break through. Not infrequently such abscesses 
originate in the soft parts, without any connection with the affection 
of the bone, break open, cicatrize, and leave behind irregular, de- 
pressed eschars. 

In chronic ostitis the general condition of the system may be but 
little perturbed, and only participates when suppviration sets in 
through febrile phenomena, etc. ; in ostitis that occurs with acute 
fever, emaciation, debility, disturbance of the sleep, loss of appetite, 
and diarrhoea, are but seldom absent. 

Treatment. — When the course is slow and the pains moderate, 
iodine ointment and mercurial plaster (when the general condition al- 
lows the use of the latter remedy) may be employed for the purpose of 
bringing about resolution, or vesicants and setons, as derivative reme- 
dies ; in the acute condition, in consequence of the very severe pains 
that are present in the great majority of cases, pain-assuaging reme- 
dies will have to be resorted to along with absolute rest of the limb, 
as resolution is altogether out of the question : cataplasms, often re- 
peated ; when the exacerbations are intense, ice and cold irrigations 
are remedies which are better tolerated than is generally believed. 

When the abscesses have broken externally, the treatment must be 
conducted with a view to facilitating the discharge of the matter : injec- 
tions into the fistulous passages and cavities are often necessary. 

Ulceration of the Bone ( Caries^ Ulceratio Ossis). — In scrofu- 
lous persons, caries most frequently develops itself from a primary 



594 DISEASES OF CHILDREN. 

ostitis in one or several bones, and is predominantly frequent in 
the spongy bones ; it is produced less often by periostitis as a re- 
sult of the ulceration of the periosteum having been propagated upon 
the bone. Caries, therefore, almost always progresses from the centre 
toward the periphery, from within outward (caries centralis, c. pro- 
funda), or, in the rarer cases, from without inward, from the periphery 
toward the centre (caries peripherica, c. superficialis). Sometimes it 
is circumscribed, and thus presents the peculiar abscess of the bone ; 
sometimes diflFused ; sometimes, again, involving only solitary parts of 
the bone, and then, again, its entire circumference (caries partialis and 
totalis). 

Caries develops itself, after the above-mentioned inflammatory pro- 
cesses, in this manner : the granulations secrete a reddish-brown fluid, 
which, in common with the degenerated fat-cells and the sparsely-pres- 
ent pus-corpuscles, represent the ichor with which the cancelli become 
filled ; then gradual atrophy of the osseous trabecuhe takes place, by 
which the bone so affected becomes soft and compressible, and finally 
disappears altogether by the destruction which attacks layer after 
layer. 

Frequently, the bony substance is not destroyed, by the gradual 
atrophy and degeneration alone, but also by necrosis, as normal parts 
of the bone Ipng next to the carious or already-ulcerated parts are 
deprived of their nvitrition, die of themselves, and form larger or 
smaller sequestrte (caries necrotica). 

The ulceration of the bone also spreads upon the surrounding 
parts, which, as a rule, have already been afffected by preceding in- 
flammation. The periosteum undergoes destruction through the pu- 
rulent infiltration of the soft parts ; the cellular tissue, particularly 
where the periosteum is destroyed, is attacked by ulceration ; in it 
large and small abscesses and sinuses form, and finally one or more 
break outwardh'", and the carious ichor escapes. In the soft parts, 
particularly those in the vicinity of the periosteum, osteophyte forma- 
tions are frequently found. 

The discharge, in most instances, is thin, of an insipid, nauseous 
odor (resembling putrid flesh), mixed with particles of bone, or, in 
tuberculous caries, with cheesy granules and flakes, and likewise -with 
small bits of bone. Soft fungous granulations exuberate around the 
mouth of the sinus, frequently blocking up its entrance, and bleed at 
the slightest touch. The fistulous tracts, as a rule, run in a straight 
or oblique direction to the afi'ected part of the bone ; sometimes they 
also make many t\vists and curves, for the discharge does not reach 
the upper surface of the bone in a straight but in a roundabout way. 
The afi'ected part of the bone will be reached by the probe with more 



GENERAL DISEASES OF THE SECRETIONS. 595 

or less difficulty, according to the course of tlie sinus, and is felt to be 
rough and uneven, as if worm-eaten, and easily impressible. (Probes, 
lead-plaster, etc., when brought in contact with the discharge, be- 
come discolored by the combinations of sulphur it contains.) 

The general state of the system suffers but little in caries, in case 
small bones at a distance from the centre of the body are attacked. 
In other cases, for example, caries of the vertebras (s. spondylarthrocace), 
it will be deranged in the highest degree. In the great majority of 
cases recovery will not take place until the cachexia, which lies at the 
root of the evil, is eradicated, and even then the caries sometimes goes 
on until the affected bone is destroyed, and, in fact, involves yet other 
adjacent parts. If recovery is to take place, suppuration and atrophy 
of the bone have to cease, the granulations then become firmer, more 
consistent, and richer in fibrin ; from these, as well as from adjacent 
structures, preferably from the hypertrophied periosteum, ossification 
next ensues, by which the loss of substance is remedied. 

The diagnosis, as well as the prognosis, is in greater part infer- 
able from what has already been said. If it is not possible to reach the 
carious bone even with the probe, owing to the comphcated course of 
the sinuses, the diagnosis can be established with perfect safety from 
the quality of the pus, the appearances of the orifices of the sinuses, 
the whole manner of origin, in unison with the locality of the nature of 
the bony part {spongious hone), and the nature of the general affection. 

Treatment of Caries, — The local treatment consists of bandasres 
and moist compresses, or moist pledgets of charpie, which have to be 
zealously renewed, while the affected limb is kept in such a position 
as not to hinder the escape of the pus. Hsemorrhages from the spongy 
granulations are best controlled by touching them with lunar caustic, 
or some mild astringent, and a graduated compress. Topical baths 
are worthy of recommendation, and, whenever the locality permits of 
their application (hand, foot, etc.), should be employed. Besides 
warm- water baths, alkaline and sulphurous baths, for the sake of 
cleanliness, should be frequently ordered, and, when very severe pains 
are present, they may be rendered narcotic by the addition of lauda- 
num, etc. 

General baths are likewise very beneficial, still they should not 
be employed where there is any great degree of debility, nor should 
any danger be combined with the bathing (for example, in caries of 
the vertebrae). Abscesses which are in direct connection with the 
bone or periosteum, and fluctuate distinctly, should be opened ; con- 
gestive abscesses as late and as seldom as possible. 

Consistent operative procedures may be resorted to in caries, liav- 



596 DISEASES OF CHILDREN. 

ing for tlielr object the exsection of smaller or larger portions of bone, 
and even amputations and exarticulations. But the indications for 
these depend so much upon the circumstances of the individual cases, 
in reference to their local affections and general state of the system, 
compared with the benefit that can be derived from an operative un- 
dertaking, that no general rules can be laid down. 

Necrosis, Gangbeke {Death of a Part of a ^one).— Necrosis 
of the bones may be brought about in scrofulous subjects by inflam- 
mation of the periosteum, of the bone-substance, or of the medulla, in 
which the bones, through the uprooting of the periosteum, or of the 
endosteum, by impermeability of its vessels, as an effect of obstruc- 
tion or pressure by exudation, having its usual nutritive conditions de- 
stroyed, must die. In this manner all causes and incentives of caries 
may also induce necrosis. 

Necrosis usually attacks only one part of a bone, and generally 
either the external bone lamellae as necrosis externa (n. superficialis), 
or the inner lamellse of a medullary canal, or a portion of the spongy 
bone-substance in the depth, as necrosis interna (n. centralis) ; it may 
also involve the bone in its entire thickness, even in its complete to- 
tality (necrosis totalis). 

Necrosis, it is true, occurs in scrofulous subjects on all the bones, 
still certain bones are predominantly often affected, especially the 
diaphyses of long tubular bones (tibia, femur, humerus, radius, and 
ulna) ; next to these the flat bones of the skull. In the spongy bones 
it is observed in common with caries ; aside from that, these are less 
frequently attacked by necrosis. The process of necrosis presents 
somewhat different features according to its site. 

(a.) In central necrosis (necrosis interna) the separated piece of 
bone that has been deprived of its nutrition— the sequestrum— lies in 
a cavity lined by granulations— sequestrum capsule— the walls of this 
cavity consist of old and new bone, which may just as well be formed 
in the medullary canal as upon the upper surface of the bone by the 
inflammatory process which is present here and there ; the osseous 
substance subsequently becomes compact, and the bone on that ac- 
count appears thicker and larger in bulk. A variable number of 
upenings, lined by granulations, form in the sequestrum capsule, 
which are continued into the cavity, and terminate externally— 

cloacee. 

The orifices on the bone are round, oval, of various sizes, and 
surrounded externally by walls of granulations ; pus escapes from 
them so long as the sequestrum is enclosed in the capsule, and, al- 
though they occasionally heal up temporarily, still, as a rule, they al« 
tvays break open again. 



GENERAL DISEASES OF THE SECRETIONS. 59Y 

When the sequestrum is removed the cavity fills up with granula- 
tions, and immediately thereafter with compact bone-tissue — provided 
the general system has not been very much reduced — the sinuses, 
in most cases, close up with contractions of the soft parts, which re- 
main visible for life. 

(b.) In superficial necrosis — the result of periostitis — the sequestrum 
is not, as a rule, entirely enclosed in a capsule. This form has a more 
favorable chance of being cured, as the sequestrum is more readily ex- 
pelled or may easily be removed ; the sheath in which it was confined 
becomes filled up with granulations, and the opening closes up with 
a cicatrix contracted down to the bone. 

(c.) In necrosis totalis a complete capsule forms, although rarely, by 
the peripheral formation of new bone on the border of the sequestrum, 
the capsule is complete, has a large cloaca, and the soft parts are 
mostly intersected by sinuses of considerable size and width. If the 
bone has been cast off, the large cloaca will be filled up with granu- 
lations continuous from the sequestral surfaces, the periosteum and the 
rest of the soft parts, in which bone-substance forms, in a longer or 
shorter time. 

(d.) Necrosis of the entire bone occasionally occurs, in scrofulous 
subjects, on the hand and foot, and is always the result of intense 
periostitis and ostitis. The sequestrum, which consists of the entire 
bone, exhibits therefore the most traces of inflammation, and is 
sometimes carious in a high degree, osteoporotic, and lies in a wide 
cavity filled with ichor and pus. After the sequestrum is removed, 
the cavity may become filled with granulations, and new circlets of 
bone may be formed from the hypertrophied periosteum and soft 
parts. 

In regard to the sjinptomatology of necrosis, every thing is essen- 
tially applicable that has been said in the consideration of periostitis 
and ostitis. A^Tien the abscess has broken or been opened, dead 
bone, if the process has already attained to necrosis, will be reached 
through the opening. In most instances this necrosed bone, when 
struck, will emit a dull, dead sound, and is felt to be smooth and 
firm ; still, in total necrosis of the spongy bones, it is also very rough, 
uneven, and fragile. It is very difficult, in such cases, to distinguish 
between caries and necrosis, especially since the discharge from the 
sequestrum capsule may also be ichorous. 

As regards tlie prognosis, it is most favorable in superficial necro- 
sis ; doubtful when the affection is located deeper, and extends over a 
large portion of tlie bone; and unfavorable when the entire thickness 
of the bone has been involved. In strumous persons, the intensity 
39 



598 DISEASES OF CHILDREN. 

and extent of the inflammation, and the subsequent suppuration, tend 
to endanger the accession of hectic fever. The fact is of great 
importance, that such cases, as a rule, can only be reHeved by an op- 
eration, which of itself is not dangerous. 

The treatment, besides the subjugation of the cachexia, which lies 
at the bottom of the malady, should especially be directed to the ex- 
pulsion or artificial removal of the sequestrum as quickly as possible. 
In superficial necrosis this indication is readily enough carried out ; it 
is only necessary to open the abscess that is forming, or to dilate the 
already -existing opening, and to extricate the sequestrum, provided 
it is completely detached from the bone ; but where this does not 
happen to be the case, then we should patiently wait, and use only 
simple dressings and bandages, in preference to all serious undertak- 
ings, such as cauterizations with the actual and other cauteries, ex- 
section, etc. In encapsulated necrosis (the central, and frequently the 
total), there is always a mechanical imipediment which prevents, or at 
least retards for a long time, the expulsion of the sequestrum, and it 
has to be removed by mechanical means, as too long delay tends to 
induce unfavorable accidents. The means of extracting the seques- 
trum from the capsule that surrounds it consists in enlarging the 
orifice sufficiently by the aid of the trephine, osteotome, small saw, or 
chisel, after which the dead bone is pulled out with the bone-forceps, 
etc. The filling up of the cavity with granulations, the cicatrization, 
and the rest of the recovery, are patiently waited for ; a simple com- 
pressive bandage is employed, and the general system is improved as 
much as possible by appropriate remedies. 

Inflammation of the Vertebra in Scrofulous Subjects. — 
Tuberculous Destructive Inflammation of the Vertebrce, Tuberculosis 
of the Vertebrce, Spondylarthrocace^ Malum Potii, lik/jyhosis Par- 
alytica. — This evil, of such frequent occurrence in scrofulous children, 
originates generally as a local manifestation of scrofula without any de- 
monstrable cause ; in some instances, however, it is produced in scrof- 
ulous subjects by traumatic influences, as falls, blows, etc. The nature 
of the disease is an inflammation of one or more bodies of the verte- 
brae, ha^dng the tuberculous character and the very marked tendency 
to deliquescence and ulcerative destruction of the bone. The affec- 
tion, as a rule, appears in the form of ulcerated tuberculosis — accord- 
ing to the above-described precedents — less frequently as decapsidated 
tuberculous nodules, generally in the centre or near the centre of the 
body of a vertebra. Those cases in which the vertebral laminae, trans- 

* The name spondylarthrocace, most frequently employed for this disease, is not 
well chosen, as the vertebral joints participate only secondarily, and may even remain 
perfectly free. 



GENERAL DISEASES OF THE SECRETIONS. 599 

verse or oblique processes, are primarily attacked, are extremely rare, 
and the affections of the articulating surfaces are still rarer. The in- 
tervertebral cartilages, it is true, undergo destruction, but only sec- 
ondarily, when the disease encroaches upon them, or when the verte- 
bral bodies sink together with resulting curvature. This happens 
after the bodies of the vertebrse have become entirely, or in greater 
part, infiltrated, when cavities have formed by the dissolution of the 
tuberculous masses, so that the vertebree are no longer able to support 
the parts resting upon them. Curvature then results, in most cases 
backward (kyphosis), but, as a rule, is combined with more or less 
marked lateral distortion (scoliosis, kyphosis scoliotica) ; it mostly 
originates gradually, seldom rapidly ; in very rapid softening, the result 
of an injury to the diseased place, etc., it is very sudden, and neces- 
sarily attended by alterations vnthin the spinal canal, hypersemia, 
inflammation, and softening of the spinal meninges, and of the cord, 
and compression of this organ, without, however, inducing in all cases 
serious phenomena ; indeed, these are very slight in some. In ciirva- 
ture of the spinal column the sympathetic nerve experiences a violent 
strain ; still, nothing positive is known in regard to the symptoms, 
thus produced. 

The affected vertebrae generate and support, in their immediate 
vicinity, an inflammatory process, which soon terminates by profuse 
suppuration. Purulent accumulations form ; most of them extend far 
down as psoas or depending abscesses on the anterior surface of the 
spinal column to below the inguinal region, or into the pelvis. Pos- 
teriorly also — on the dorsum — such abscesses make their appearance, 
sometimes attaining to enormous sizes. These abscesses break but 
very rarely into the spinal canal. They contain thin pus or ichor, 
mixed with decomposed or degenerated tuberculous masses, as also 
frasTnents of bone and Ho-amentous shreds ; in most instances the mat 
ter has a very pungent, nauseating odor, colors the probe black, etc. 
(S. caries). 

In the contiguous parts, on the other hand, new formation of bone 
may be combined with destruction of the vertebrae, and the adjacent 
vertebrae, or the spaces between the laminae and the processes, may 
also frequently be found studded and filled out with dentated, irreg- 
ular bone-substance. Spontaneous dislocation of the vertebras, with 
the exception of the first two cervical, has very seldom been ob- 
served. 

The first signs of the disease relate to the spinal column, and con- 
sist in painful sensations emanating from it. Small children are rest- 
less, display symptoms of discomfort, cry when the back is touched, or 
when the}' are moved about quickly ; larger ones carefully avoid these, 



600 



DISEASES OF CHILDREN. 



and sometimes complain of stationary, and sometimes again of fugitive 
pains at the diseased part, or in its neighborhood. 

An attentive examination of the back and spinal column should be 
instituted at the ver}^ commencement of the complaints of pain ; the 
back and spinal column should be felt and percussed all over, and the 
patient should be made to perform various bodily movements, for by 
this it will be more easy to define accurately the location of the pain. 
With these local symptoms there are also general phenomena present 
when the disease has once attained to any degree, for, loss of appetite, 
febrile excitement, sleeplessness, and diminution of the mental abili- 
ties, soon come on. 

At a further stage of the evil, important local derangements super- 
vene, namely, curvature of the spinal column backward and laterally, 
with' which a deformity of the thorax progresses hand in hand, for the 
ribs stand off at a greater distance on the side of the convexity of the 
curvature than on the concave' side. With this, modifications in the 
remote phenomena, according to the locahty which the affection em- 
braces, manifest themselves. 

(1.) Spondylarthrocace thoracica begins in the manner described ; 
in addition, the patients complain of pains in the limbs, of a tickling 
sensation and formication in the calves and thighs, of pressure in the 
prEecordia and abdomen ; and not infrequently spasmodic affections in 
the parts mentioned also become superadded, quickly followed by con- 
stipation and difficulties in the nutrition. Every movement of the 
vertebrse is studiously avoided ; the neck is drawn backward and short- 
ened as much as possible, so that the head seems to be stuck in deep- 
ly between the shoulders, the elbows are kept at the sides, and the 
hands rest on the thighs, the arms thereby forming a support to the 
upper part of the bod}". Psoas abscesses now form, paralyzations 
supervene, the general symptoms assume the character of hectic fever, 
not infrequently accompanied by Bright's degeneration of the kidney, 
and death ensues after a shorter or longer period. Still, the patient, 
if his strength has not been exhausted in too great a degree, may es- 
cape with his life (a not very frequent occurrence, it is true, in any 
stage of the local affection), of course, with an incurable curvature of 
the spinal column and thorax, along with paralyzations of the lower 
extremities, rectum, and bladder, which, as a rule, likewise defy all 
manner of treatment. 

(2.) Spondylarthrocace cer\4cales, angina Hippocratis. 
The further downward toward the thoracic spinal column the affec- 
tion is situated, all the more resemblance has the morbid picture to 
the one just sketched ; but, in addition, the phenomena on the part of 
the upper extremities, in the form of spasmodic or paralytic derange- 



GENERAL DISEASES OF THE SECRETIONS. 601 

ments, come into consideration; the further upward the disease, all the 
more plainly the symptoms manifest themselves on the part of the 
digestive, vocal, and thoracic organs. (Hence the old denomination, 
angina Hippocratis.) In this form of the disease, swelling of the re- 
gion of the neck is observed, which sometimes attains to a considerable 
size, and the place of curvature may thus remain hidden by it from the 
examining finger. These swellings, in most instances, are tense, firm, 
and hard, and have hence acquired the name of " tumor albus nuchse " 
(analogous to the tumor albus of the joints). The greatest danger 
attends the disease when it is situated on the first and second cervical 
vertebra, because at this point it may readily lead to compression of 
the medulla oblongata,* and, OAving to the importance of this organ, to 
a speedily fatal termination. The cause is, the great mobility of the 
joint connections, so soon as the ligamentum transversum atlantis 
is destroyed or materially injured. 

The movements of the head are painful ; they are avoided as much 
as possible,f and the nape and neck are kept stifi", or the movements 
of the head are aided by the hand. Generally the pains in the head 
are quite severe, and torture the patient very much, especially at night ; 
the difficulty of swallowing is frequently great, particularly when the 
disease has reached the stage of the formation of retropharyngeal ab- 
scesses, which, OAving to the magnitude which they occasionally attain, 
may altogether prevent the patient from partaking of food or drink. 
This form of caries of the vertebrae, when the disease is to any degree 
intense, kills the patient either by the above-mentioned luxation of the 
upper cervical vertebra, or by its invading the meninges and brain, or 
through exhaustive discharges. Milder forms may improve and ter- 
minate in recovery — as a rule, with permanent or difficult-to-be-im- 
proved deformity in the attitude of the head. (A kind of caput obstl- 
pum [torticollis] is indebted for its origin to this disease.) 

(3.) Spondylarthrocace lumbalis and sacralis. 

The site of this form, which is least frequently observed, is the lower 
section of the lumbar spinal column, the sacrum, and also a contiguous 
part of the coccyx in rarer instances. The real pains are not infre- 
quently preceded by unpleasant sensations in the thighs — in the form 
of ischias. The child lies in bed, on one side, with contracted thighs, is 
only able to rise with great difficulty, in which act it is obliged to support 
the region of the buttocks or hips with the hands (therein bearing some 

* [Either by the spinal column curving at a very acute angle, or by the dislocation 
of one body of the vertebra from the other, thereby compressing or even tearing the 
medulla oblongata. 

f The child (as in a case at present under observation), when desirous of looking 
at an object at its side, rotates the whole body toward it.] 



602 DISEASES OF CHILDREX. 

resemblance to coxitis). Purulent collections take place in the pelvis 
and may escape througli the obturator foramen or into the rectum ; 
they seldom make their appearance in the inguinal region. Paralysis 
of the sphincters and bladder is rare, as the affection is located deep- 
ly, and the nerves which control these organs are found above the 
site of the disease. Life is jeopardized by the suppuration with its 
eJBFects ; fatal meningitis or myelitis has also often been seen to ensue. 

Therapeutics. — The treatment, besides being directed to the sub- 
jugation of the cachexia, should be conducted with the view of pre- 
venting the spreading of the disease upon delicate structures, the brain, 
meninges, and spinal cord. Every mechanical "vdolence and all in- 
juries to the spinal column in particular, when the disease is confined to 
the upper section — for the reasons mentioned — are to be prevented 
with the utmost care. To accomplish this indication, a horizontal 
posture on the back, or, if this be impossible, the lateral decubitus 
upon a good upholstered mattress, should be prescribed for the patient 
so long as the morbid process is active, and he should be retained in 
that position, by mechanical appliances, under all circumstances. In 
order not to deprive the patients of the enjoyment of fresh air, they 
should be taken out upon the couch as often as possible. 

[The best appliance for this purpose is the plaster-of-Paris jack- 
et, or a corset with steel braces, made to fit the body properly, and 
sufficiently fii'm to support the head and shoulders, thereby taking 
off the weight and pressure from the diseased vertebrae.] 

Besides th« internal use and local application of narcotics in the 
form of opium and ointments containing morphine, derivatives will 
have to be employed against the violent pains. Small blisters (upon 
which morphine is subsequently strewn) are very advantageous. The 
seton, however, will not infrequently be found to be more potent and 
none the less advantageous against the intense painfulness. 

Depending abscesses, that are not voluminous, should be left un- 
opened as long as possible, since the disease, in most instances, makes 
more rapid progress after they are opened : if they have attained to 
great dimensions, are attended by excessive pains, and redness and in- 
flammation of the integument, indicating their approach to a speedy 
bursting, they may be opened and the pus allowed to escape. 

(e.) Joints. — Inflammations of the joints occur very frequently 
in scrofulous individuals as local manifestations of the general disease, 
without it being possible to demonstrate any other external cause, and 
are, as a rule, attended by other phenomena of scrofula in some remote 
part of the body. Pathologically, these inflammations difi'er in no essen- 
tial respect from others that have originated through injuries, rheu- 
matic influence, etc., but their phenomena derive a sufficiently peculiar 



GENERAL DISEASES OF THE SECRETIONS. 603 

character from the general disease which lies at the bottom of them. 
They begin and terminate either in an acute or chronic form, and take 
their origin either from the epiphyses of the bones that enter into the 
formation of the joint, or from the membrane which lines the joint, the 
synovial (sometimes from both at the same time), and in this manner 
present in the former case the clinical picture of arthrocace, in tho 
latter that of the fungous inflammation (tumor albus). 

I.— Artlirocace. 

The spongy joint-ends are attacked by inflammations which ter- 
minate in suppuration and caries, after the manner described in ostitis, 
etc. Suppurative degeneration (dehquescence) sets in, the cortex of 
the bone is involved in the carious process, and becomes perforated, ab- 
scesses form in the surroxmding soft parts, while the pus or ichor, after 
the destruction of the cartilaginous part, tunnels a passage for itself 
toward the cavity of the joint, and quickly sets up in it a suppurative 
inflammation. After the cartilaginous coating of the joint has become 
disintegrated, and the synovial membrane and the ligamentous ap- 
paratus destroyed, the carious joint-ends of the bones will protrude 
into the enlarged cavity, which is filled with ichor, by which exfoHa- 
tion of the joint-ends of the bones not infrequently takes place. Dislo- 
cation of the ends of the bones is very apt to ensue, as the coaptating 
apparatus is attacked by the destructive process of the disease. 

The kind of inflammation just described attacks the hip-joint most 
frequently of all. 

II.— Fungus Artlcull. 

In other instances the synovial membrane is found predominantly 
affected. In the incipient stages of the inflammation it is seen to be 
lax, injected, covered with small projections — granulations. It has a 
villous or varicose appearance ; by-and-by these granulations exuberate 
into shaggy, bulbous, inosculating excrescences, which project into 
the cavity of the joint; the synovial membrane is thickened, infil- 
trated, and permeated by pus. The vicinity of the joint also partici- 
pates in the inflammation ; the cellular tissue and the ligaments of the 
joint, etc., are infiltrated with a gelatinous or lardaceous material, and 
pervaded everywhere by plethoric exuberations of connective tissue in 
the form of spongy masses. In consequence of the suppuration, the 
soft parts are not infrequently perforated by sinuses coursing in various 
directions, which often reach the immediate vicinity of a joint, in or- 
der, after perforating the capsule, either to terminate into it from 
without inward, or in a contrary manner. The subcutaneous cellular 
tissue is infiltrated, in most instances, witli serum, and in a state of 



604 DISEASES OF CHILDREN. 

hypertrophy ; the integument is tense, white, and glistening, so long 
as no opening has formed (a phenomenon which is often protracted for 
some time) ; hence the older denomination, tumor albus. The muscles 
around the joint generally become flabby, and atrophic, and undergo 
fatty degeneration. The cartilages of the joint either become coated 
by the fungous extuberations and degenerate into the same, or they 
quickly deliquesce through the abnormal contents of the cavity of the 
joint, and disintegrate to a pulpy, fatty mass. At a further stage of 
the disease, the bones are hkewise invaded, and, in fact, in the ma- 
jority of these cases, become carious, so that in the end this form of 
mflammation may display the greatest similarities to the former. In 
both we not infrequently have the opportunity of observing in the 
vicinity of the joint, either in tlie osseous or in the soft parts, new- 
formed bone-substance, in the shape of irregular projections, small 

spiculse, and the like. 

In rarer instances the inflammation issues simultaneously from the 
bone and synovial membrane; here, however, such abundant exuberat- 
ing granulations do not form so readily from the latter ; a very rapid 
suppuration in the cavity of the joint takes place instead. For the 
rest, the relative condition of the soft parts, etc., is the same. 

The fungous inflammation is principally observed on the knee- 
joint. 

Symptoms.— Scrofulous inflammation of the joints may appear as 
an acute, even very acute affection, and terminate as such, or subse- 
quently pass over into the chronic state ; the beginning, however, 
may also be chronic, and remain so, or change to the acute form. 
In the latter case, when no febrile movements, due to other re- 
mote scrofulous manifestations, happen to exist, chills, alternating 
with sensations of heat, loss of appetite, and great restlessness, super- 
vene, along with which symptoms, pains in the afi'ected joint and in its 
viciiity, not infrequently extended for a considerable distance, mani- 
fest themselves, either immediately or in a short time thereafter. At 
first, they are mostly intercurring, dull, and aggravated on pressure and 
motion ; soon, however, they become constant and intense, and some- 
times become so excessively severe, when an attempt is made to move 
the affected joint, that the patient will cry out loudly. This is also 
adequate to explain the marked tendency of the joint to assume a cer- 
tain position, and, indeed, such a one as wiU bring about the utmost 
possible equipoise, and cause as little tension as possible to the 
ligaments and muscles lying over the joint, because the traction thus 
obviated from the affected part serves best of aU to make the pains 
bearable. Thus, for example, in coxitis the thigh is brought into a 
state of flexion, adducted and rotated inward to a moderate degree • 



GENERAL DISEASES OF THE SECRETIONS. 605 

ill the inflamed elbow-joint the forearm is placed midway between 
pronation and supination. Swelling of the joint, as a rule, soon 
becomes noticeable,* which is either limited to it, or extended for 
some distance beyond, and is of a round, spindle form, irregular in 
shape and size, and soft and doughy, or hard, tense, and firm, and 
only later on exhibits the signs of softening and fluctuation. 

The skin is sometimes reddened, tense, and permeated by small 
and large vessels (particularly venous inosculations), is increased in 
temperature ; or it may present no change of color, may be raised into 
smaller or larger folds, and be devoid of any perceptibly great amount 
of warmth. As the matter produced from the inflammatory product 
in the deeper structures and about the joints approaches the upper sur- 
face, the skin becomes red, not infrequently bluish, and the epidermis 
rises up like a blister. After a spontaneous or artificial opening has 
ensued, the pains subside for some time, as a rule, and the patient 
feels much relieved, but they invariably soon return, although not 
always in so severe a degree as before. In the further effects, the mor- 
bid pictm-e assumes a different shape, according as to whether the dis- 
ease runs through an acute course or approaches more to a chronic 
one. In the first case, death, as a rule, ensues some time after the 
breaking of the abscess, under pysemic phenomena or consumptive 
fever ; in the second case, the malady may last for a long time, and 
death, at some future period, occur through exhaustion, or from a new 
accession of the inflammation, or the process may assume a favorable 
turn, and result in one of the remote terminations to be mentioned. 

The chronic form of the inflammation mostly begins with a mod- 
erate fever ; the pain, as a rule, is also slight at first, and is only 
aggravated by prolonged exercise or by severe pressure on the joint, 
or the patient suffers somewhat more from them in chilly and wet 
weather. In this manner the process may go on for a long period be- 
fore suppuration and bursting occur, by which the conditions undergo 
a change, according as to whether a diffused inflammation sets in, or 
the disease retains its chronic character. If the former happens to be 
the case, all the symptoms of an acute inflammation of the joint with 
a rapid and severe course may then supervene. In addition to the 
unfavorable terminations described, the joint-inflammations, especially 
when they are treated in the proper manner, generally and locally, 
may present the following results : 

(1.) Recovery without any decided derangement of the function 

of the joint. This termination presupposes that the disease had not 

attained to a too serious degree, and that the cartilages and ligaments 

of the joint had suffered no extensive destruction. But, since these 

* [This, in fact, is often observed before the pain or any other symptom.] 



606 DISEASES OF CHILDREN. 

favorable preconditions are the attributes of the fewest cases, this ter- 
mination belongs, therefore, to the greatest of rarities. 

(2.) Recovery, with diminution of the function of the joint, owing 
to the inflammatory process having brought about such morbid altera- 
tions that a perfect restoration is no longer possible. In such cases, 
when the osseous and cartilaginous parts have suffered in a compara- 
tively less degree, but the capsule, the ligaments of the joint, and 
the surrounding soft j^arts, on the contrary, have experienced a great 
deal of destruction, and the healing has progressed with contractions, 
adhesions, and fusions, it results in stiffness, with impaired mobility 
of the joint (false anchylosis), or, when the osseous parts and carti- 
la^es have also been more seriously affected, and, by the formation of 
new bone during healing, become uniformly united, true anchylosis 
may ensue. The latter result is also subject to a number of operative 
procedures — as healing with at least some mobility is more advan- 
tageous for some cases, and is sought to be accomplished by surgeons 
through an operation. False anchylosis, in the just-mentioned views, 
not infrequently furnishes a cause for operative undertakings, while 
true anchylosis, on the other hand, when it is combined with more 
marked deformity, becomes the subject of a manual treatment. 

(3.) Heahng, with luxation of the bones forming the joint ; in 
the course of the inflammation after the tendons and ligaments 
have been destroyed, as also after perforation of the capsule has oc- 
curred, luxation of one or more bones from their natural position will 
result through any, in most cases trifling, causes (luxatio spontanea). 
When such a dislocation has existed for some time, it seldom becomes 
a promising object for surgical interference ; only now and then, in in- 
flammations which have already expired, and when the dislocation has 
not existed for a very long time, can a successful result be looked for 
from a surgical operation. 

Therapeutics. — The treatment resolves itself into two parts : (1), in 
a general one, directed against the fundamental disease ; and (3), in 
the topical against the local affection. 

In regard to the latter, a perfectly quiet and proper position of the 
diseased part is of the greatest importance, and the first consideration 
of every treatment, if it is to be crowned Avitli success. It has already 
been remarked that the patient will instinctively select a certain pos- 
ture for the limb ; but, since this position of the affected joint will 
generally be permanent throughout the entire course of the inflamma- 
tion, and in some cases will prove unfavorable to the future exercise of 
the limb, it is therefore necessary to pay especial attention that the 
position is such a one that, at the termination in anchylosis, the use- 
fulness of the limb will not be impaired in a too high degree. The 



GENEEAL DISEASES OF THE SECnETIONS. 607 

patient, as a rule, soon becomes accustomed to the direction given 
to the limb, although it is just the contrary to the one he had him- 
self selected. Uninterrupted rest is to be maintained so long as 
there is any sign of inflammation, and only after it has entirely ter- 
minated can any movements of the limb, even with the utmost jdos- 
sible care and protection, be allowed. The pains are best allayed 
by the internal use of narcotics, as also the local application of oint- 
ments containing morphine, etc, ; but, if they have become very in- 
tense, then we should not hesitate to use cold, or even to apply ice. 

[The best remedy for the relief of the pain is the separation of 
the inflamed surfaces of the joints, by means of an extension and 
counter-extension apparatus.] 

Many remedies have been recommended as resolvents, to facilitate 
the absorption of the exudation. Those most frequently used are the 
preparations of iodine — iodide of potassium ointment ; Richter's solu- 
tion of iodine for pencilKng the part — iod. pur., kali hydroiod., aa 3 j, 
glycerine 3 ij. The use of mercurial preparation requires much 
caution. 

Johert has lately recommended nitrate of silver as an excellent 
remedy in chronic inflammations of the joints. At first an ointment 
containing argent, nitr. 3 j to adipis 3 j, of which from 3 ss to 3 j is 
rubbed in twice daily ; it is gradually made stronger, until it contains 
3 iij of nitrate of silver to 3 j of fat. Setons, issues, moxas, and the 
actual cautery, have been used as derivatives ; the latter, especially, 
has acquired a great reputation in Musfs hands. Nevertheless, the 
result falls far short of the expectations that have been entertained. 

Numerous baths are also employed for the treatment of the cachexia 
as well as for the local affection ; but these are only permissible with 
the understanding that the change of posture and movements will not 
cause the patient more harm than good. Iodine and bromine baths 
have acquired a certain amount of reputation ; baths, with common 
cooking salt, deserve especial recommendation on account of their 
simplicity and cheapness. JPriesiiitz's method of treating joint-aff"ec- 
tions may be added here, which, in its entire extent over the whole 
body, should be discarded on account of the small amount of strength 
the child has to spare in the exhausting cure ; but, locally to the afi"ected 
joint, it deserves full consideration. Where siippuration exists, care 
should be taken to allow the pus to escape freely ; the sinuses are to 
be dressed with simple, unirritating appUcations. Abscesses develop- 
ing themselves in the vicinity of a joint, and bulging up under the 
integument, are to be opened as early as possible ; on the other hand, 
the opening of abscesses which are in connection with the joints, or, 
after having perforated the capsule of the joint, subsequently reach 
beneath the sldn, should be delayed as long as possible, if the strength 



608 DISEASES OF CHILDREN. 

of the patient is sinking and giving out, for then the process, as a 
rule, runs faster toward a fatal termination. 

When purulent degeneration of the joint ensues, and there is no 
longer any hope, from the most appropriate local and general treat- 
ment, that anchylosis vnU. take place, and the circumstances be- 
come aggravated to such a degree that hectic consumption is appre- 
hended, then surgical interference comes into consideration as a der- 
tiier ressort of saving the life of the patient, provided the general con- 
dition — upon Avhich, of course, every individual case must be judged 
separately — allows an operation to be undertaken. In these cases 
there may be a question about the removal of the affected part of the 
bone — resection — or about amputation of the limb, or exarticulation. 

In joint-inflammations that have become totally chronic, the use of 
a graduated bandage upon the affected limb, with or without the sim- 
ultaneous employment of remedies to accelerate absorption, particu- 
larly the preparations of iodine, will be found to be of great benefit. 
Compression may be effected with flannel or ordinary bandages, or a 
plaster of paris or starch bandage is applied around the joint for this 
purpose, by which it is also kept in the desired position. Sinuses 
and ulcers about the joint do not serve as contraindications. All that 
is necessary in that case is to cvit out holes in the apparatus corre- 
sponding to the size and position of the vilcers, and to remove the 
w^liole dressing somewhat oftener than w^hen the sldn is whole. If 
the anchylosis, so far as it hinders the use of the affected limb in a 
marked degree, affords causation for treatment, then, according to the 
nature of that condition, simple or serious operations will have to be 
resorted to. To the first belong local and general baths, douches, fo- 
mentation, supported by passive movements, apparatus, and instru- 
ments ; to tlie latter, the forcible breaking up of the adhesions and 
extensions, either by the aid of machinery or under aniesthetics, 
according to Langenheclc's precepts. Subcutaneous section of thick 
ened aponeurotics, ligamentous structures, etc., may be previously 
performed to facilitate the operation. In bony anchylosis, resection 
of various-shaped pieces of bone may be resorted to. 

Scrofulous Inflammation" of the Hip-joint [Coxitis Scrofu- 
losa, Coxarthrocace, Coxalgia, 3forbus Coxarum, JLuxatio Sponta- 
nea, Freitcilliges Ilinhen, Sip Disease). — This disease occurs by far 
the most frequently of all inflammations of joints, and attacks scrofu- 
lous children in various ages of life, very often at the time of the sec- 
ond dentition. It generally takes its rise from the bony parts of the 
joint — most frequently from the head of the femur — less so from the 
synovial membrane, or the surrounding soft parts. It presents varie- 
ties in its stages, according as the course has an acute or chronic char- 



GENERAL DISEASES OF THE SECRETIONS. 609 

acter. In the acute inflammation, violent pains qiiickly come on in 
the liip-joint and its neighborhood, which spread predominantly upon 
the inner side o£ the thigh down to the knee, and become aggravated 
upon pressing the hip-joint, or on attempts at walking. The latter 
are therefore carefully avoided ; the thigh is drawn up against the 
abdomen, and rotated slightly inward. The pains usually increase in 
severity at night, and often rob the patients completely of sleep ; con- 
jointly with it, as a rule, active febrile movements are present, which 
often reduce the strength remarkably rapidly. It is extremely diffi- 
cult for them to stand or walk, sometimes altogether impossible ; 
the child throws the weight of the entire body upon the sound limb, 
draws up the afiiected side of the pelvis, and is in danger of falling. 
The region of the hip-joint, particularly the buttock, appears more or 
less swollen, the fold is generally longer and less marked than on the 
other side. Both extremities are either equally long, or the diseased 
extremity appears somewhat shortened or elongated. When the in- 
flammation does not undergo resolution — the rarer case — it will pass 
over into suppuration attended by the most serious aggravations of 
the general and local phenomena ; abscesses then form, either in 
close proximity to the hip-joint, or at some distance from it, commu- 
nicate with the purulent accmnulations in the joint, finally break open 
after reddening the integument, and are the causes of keeping up an 
intense suppuration and purulent infiltration. In cases where the de 
struction of the osseous parts goes on rapidly, the head of the bone 
becomes smaller and the acetabulum larger, thus giving rise to a dis- 
proportion of spaces, and, as a result thereof, we will have dislocation 
of the head of the thigh-bone, and an actual change of its relative po- 
sition in comparison with its fellow. Soon after the bursting of the 
capsule of the joint, the fever assumes a hectic character, the strength 
of the system sinks, the patients become notably emaciated, and the 
muscles of the hip and thigh weak and soft. They often succumb at 
this stage to the continuous consumptive fever, which may also be 
accompanied by pyajmic phenomena, as the entire process may be of 
but very short duration. Only in rare instances does the suppuration 
ever grow less ; in such cases, small pieces of bone may exfoliate and 
be expelled, and the orifices of the abscesses then close up. 

In the chronic course of hip-joint disease, close observation will 
often show that the child, on walking, drags or draws one extremity ; 
it complains of slight fatigue or weakness of the limb ; the walk, 
when active, becomes unsteady, during which, likewise, the greater 
part of the weight of tlie body rests upon the sound side of the 
pelvis and extremity. The pains are not intense nor continuous, 
vaguely course about the thigh, and are rheumatic in character; 



GIO DISEASES OF CHILDREN. 

not infrequently, they are present in the raorning", disappear during 
the day, and reappear in the evening, accompanied by febrile ex- 
citement. Very little that is abnormal may be observed about 
the hip-joint. Still, if the patient is told to raise up the affected 
extremity, a slight rotatory movement of the thigh inward, along 
with a small degree of abduction, will be noticeable. These cir- 
cumstances, in the insidious course of the evil, may last for months 
(even j^ears), and alternate also, frequently, with improvement and ag^ 
gravation. 

After a certain period the morbid picture changes without any ap- 
parent decided external cause, and inclines more and more toward 
the acute form. Tlie well-known pains in the knee come on, which 
are very intense in most cases, without, however, becoming aggra- 
vated on touch or pressure. These pains are explained by the sup- 
position that the external cutaneous branches of the obturator, or of 
the internal saphena nerve, are irritated. The walk becomes still 
more difhcult, the patient limps, the toes only touch the ground, 
while the weight of the body comes to rest upon the extended sound 
limb. In the sitting posture the buttock only of the sound side rests 
upon the seat, and, when the patient desires to pick up some object 
from the floor, he only bends the sound knee, while the diseased 
extremity is kept stifiF and extended. 

At a further stage of the disease certain symptoms supervene, 
which have given rise to the most varying views and significations, 
and which have already been alluded to above, namely, an elongation 
or shortening of the affected thigh in comparison with its fellow, 
without an}' change in the position of the bones, entering into the for- 
mation of the joint, having taken place. Formerly it was almost 
wholly assumed that the head of the femur was pressed out of the 
acetabulum by the exudation, and displacement of the femur thus 
produced, or it Avas draAvn into the acetabulum by strong muscular 
contractions, and the extremitj'' shortened. All evidences, however, 
tend to show that the supposed shortening or elongation is no 
actual condition but only an ajjparent one, produced . by the sink- 
ing of the pelvic moiety on the diseased side, or through displacement 
upward of the pelvis on the affected side, with subsequently resulting 
curvature of the spinal column. For the purpose of clearly elucidat- 
ing this circumstance, and to avoid falling into a very possible error, 
certain accurate measurements are to be instituted ; but first it is 
necessar}' to bring both anterior superior spinous processes into the 
most direct line possible, the patient being on his back, and a rectan- 
gular line draAvn from the xiphoid cartilage of the sternum, directly 
to its centre. T!ien both extremities should be placed in per- 



GENERAL DISEASES OF THE SECRETIONS. 611 

fectlj exact positions, and both sides measured from the spinoxis pro- 
cesses to the internal condyle and internal malleolus. 

At tins stage, i. e., whUe the deformity is only apparent, the disease 
may also be brought to a stand-still and cure, and the phenomena of 
shortening or lengthening disappear, provided no alteration in the con- 
figuration of the pelvis and spinal column has taken place, sufficient 
to prevent the pelvis from regaining the straight position. 

But, on the other hand, if the disease goes on unchecked, a more 
or less marked swelling of the fundament and region of the hip-joint 
takes place, the integument becomes red and soft, fluctuation is dis- 
tinctly felt, and these conditions are soon followed by the breaking of 
the abscess. This, however, does not always take place in the neigh- 
borhood of the joint, the pus may tunnel its way downward, and make 
its appearance in the region of the knee, or even still lower down. 
It may also perforate the capsule of the joint. In the majority of 
cases, this occurs at its posterior or under side, where on the one 
hand it is less dense, and on the other, also, the greatest amount of 
pressure is exerted by the head of the femur, especially when the 
patient is left to himself to select his own position. Pus may some- 
times be observed escaping from the cavity of the joint through the 
communicating place, with the bursa beneath the iliacus internus and 
psoas magnus muscle, into the latter, and thence into the pelvic 
cavity; in addition it may also run into the pelvic space by perforating 
the ilium along the gluteal group of muscles. The sinous openings, 
left after the bursting of the abscesses externally, are generally sur- 
rounded by spongy, readily-bleeding granulations, which project above 
the level of the skin ; extensive ulcers, also, not unfrequently form upon 
the skin and subcutaneous cellular tissue at the places corresponding 
to the perforations. 

In progressive destruction of the osseous substance of the bones, 
entering into the formation of the joint, there originates a shortening 
of the neck of the femur, and an enlargement of the acetabular space, 
thus resulting in a disproportion, which is the fundamental condition 
to the process called luxatio spontanea, and is attended by true 
shortening or elongation of the thigh, in comparison to its fellow. 
In the advanced carious process, dislocation of the head of the 
femur or the residue thereof very frequently occurs by the mere alter- 
ing of the position in bed, by raising the patient, or by the energetic 
contractions of the extensor muscles, and may be effected in different 
directions. Most frequently, however, the luxation takes place up- 
ward and backward upon the dorsum ilii, because the head, by the 
position of the thigh, comes to press mostly against the posterior bor- 
der of the cotyloid cavity, and its carious destruction is completed at 



612 DISEASES OF CHILDREX. 

an earlier period, and the head of the bone then has but a very slight 
impediment to overcome. When that portion of the ihum, upon which 
the iilcerating caput femoris comes to rest, is also attacked by carious 
disease, perforation of the ilium, with penetration of the head into the 
pelvic cavity, may take place, although this event may also happen, 
without dislocation, by perforation of the floor of the acetabulum. 

Besides the usual form of dislocation of the head of the thigh- 
bone, it may also occur into the ischiatic notch, obturator foramen, 
or upon the horizontal ramus of the pelvis ; these are, however, 
very rare and exceptional instances. Total exfoliation of the head of 
the bone, and its expulsion through a large sinus, have also happened 
in the experience of some surgeons ; in favorable cases a cure may 
take place after these processes, not, however, without very great 
deformity. 

When an arrest in the progress of the disease, and recovery from 
the evils under consideration after luxation, have taken place, the just- 
described eff"ects will remain behind and impair the usefulness of the 
limb in a high degree. In fortunate cases a kind of joint-cavity forms 
at a future period near the old one, in which the head is able to per- 
form some evolutions, but in most it is held firmly in its new place by 
adliesions and newly-formed structures. 

Most frequently, however, the dislocation of the head of the femur 
is the precursor of the last stages of the disease. The suppuration 
constantly becomes more and more profuse, not infrequently large 
portions of the integument slough ofi", and the extremity, in conse- 
quence of pressure on the veins or obstructions within them, becomes 
oedematous. The fever assumes more and more the hectic character; 
shiverings or actual chills come on, and the patients die exhibiting the 
picture of general consumption. 

In the acute form of inflammation of the hip-joint, as also in the 
fullj'-developed disease, there will be no difficulty whatever in forming 
the true diagnosis ; in the chronic course, on the contrary, it may, in 
its incipient stages, be entirely overlooked or confounded with other 
processes. At the commencement of the disease it is not unlikely to 
be mistaken for rheumatic affections, or for coxalgia, stiU an accurate 
observation of the dehneated symptoms, and the absence of phenomena 
peculiar to those diseases will plainly point out the true diagnosis, 
although the general state of the system had not yet directed any 
special attention to the local trouble. 

Therapeutics. — The most important part ia the treatment of coxitis 
IS absolute rest of the lower extremity and hijD-joint, and this indica- 
tion is to be carried out with the limb in the extended position. For 
this purpose the same apparatus is advantageously resorted to as ia 



GENERAL DISEASES OF THE SECRETIONS. 613 

used in fracttires of the neck and body of the femur, and preferably 
with double splints for the outer sides of both extremities, which 
should reach up to the axillas, and be united below by a foot-board, 
while the pelvis is secured to the apparatus by a strap or girdle. No 
matter how much the patients are opposed to this apparatus at first, 
especially if they have been allowed to retain the thigh in the flexed 
and adducted position which they had themselves selected, they will 
readily become accustomed to it, especially if, at first, it is only ap- 
plied for a while and gradually kept on for a longer time. 

Starch and plaster-of-paris bandages have also been used with ad- 
vantage for the purpose of keeping the limb and hip-joint immovable : 
these may especially be used in the milder cases, for in these the dis- 
placement of the pelvis does not require so great a counteracting 
power as in the severer.* 

* [A variety of apparatus has been invented for the purpose of securing complete 
immobility to the affected hip-joint. M. Bonnet's grand appardl, and Bauer's 
wire-breeches — which is a modification of the first — are so constructed as to fit to the 
pelvis, both thighs, legs, down to the feet. The apparatus being well fitted and padded, 
is secured to the parts by bandages and leather straps, thus securing perfect immo- 
bility for the lower half of the person. Barwell, of London, however, finds fault 
with this appliance, on account of its interfering with the movements of the sound limb 
and spinal column, without securing perfect immobility to the diseased hip-joint, and 
has had a splint constructed which simply restrains the movements of the affected 
limb. It consists of a pelvic portion made of wire gauze and reaching from the spine 
of one ilium to the other, thus embracing both sides of the pelvis and the sacrum, 
wide enough to reach from the crista ilii to the trochanter on the sound side, 
and extending from the pelvic band on the diseased side down the outer aspect of 
the thigh as far as the knee. The instrument is also secured to the trunk by an 
india-rubber band surrounding the body. It should be well lined and padded, and 
retained in place by bandages and adhesive plaster. As regards the use of counter- 
irritants, there is great diversity of opinion. No doubt seems to exist as to their 
usefulness in the early stages. Thus, in subacute synovitis of the hip-joint, blistering 
and the use of savine ointment will suffice, but, when the severe symptoms of ostitis 
show themselves, the more potent cautery or caustics are required. Potassa fu8» 
is frequently resorted to, but at this stage is properly superseded by the potential 
cautery. The splint should not be removed until some period of time has elapsed 
after the subsidence of all symptoms of inflammatory action, and after its removal 
the patient should remain in bed for a few days, and gradually undertake the exer- 
cising of the limb. 

At a further stage of the disease, when lengthening, with abduction and flexion, 
has existed for some time, the patient will suffer intensely from a very peculiar and 
painful clonic spasm of the muscles of the thigh, aggravated at night, depriving 
him of all sleep, and indirectly undermining the health. Narcotics, even in very large 
doses, have little if any quieting effect, so that, generally, it is better to place the limb 
in a straight position and retain it by counter-extension, a measure easily accom- 
plislied, as the pain is chiefly due to spasmodic muscular contraction, caused by nei- 
vous irritation, and is overcome by the extension. If the deformity is slight, and the 
40 



614 DISEASES OF CHILDREN. 

Lately, resection of the femur has also been successfully performed. 
The operation is comparatively easy, as, the ligaments and capsule of 
the joint having been almost wholly destroyed by the various processes, 
one long incision will suffice to reach the head of the bone ; it is then 
turned out of the socket and sawed off by the ordinary or chain saw. 
Other methods of oi:)eration are based upon the substitution of a trian- 
gular or an elUptical incision for the straight one, but in that respect 
no positive rules can be laid down, for the sinuses, which are invariably 
present, will materially affect the direction that is to be given to the flap. 

Where a cure has resulted with dislocation of the head of the bone, 
the deformity and hinderance in the use of the limb may be sought to 
be remedied by surgical operations. Where the dislocation is but of 
short duration, the usefulness and direction of the limb may, in a meas- 
ure, be improved by an operation best adapted to the individual case, 
and afterward bettered still more by a properly-adjusted instrument. 

ScROFULOTJS Intlammation" OF THE KxEE-joiNT ( Gonarthroccice, 
Gonalgia, Tumor Albus Genu — White-swelling of the Knee). — This 
disease takes its starting-point either from the bony parts of the joint, 
and preferably from the condyles of the femur, less frequently the 
head of the tibia or — but, in fact, oftenest — from the syno\aal mem- 
brane, with or without the ligaments of the joint. The phenomena 
vary according as to whether the disease occurs in an acute or chronic 
form ; in the former case they may manifest themselves in an intensely- 
rapid and violent manner, and in a short time terminate in suppuration 
of the joint, or even fatally — in the latter, the signs are often at first very 
slight, almost unnoticeable, and onl}^ after a while become aggravated. 

Symptoms. — The affection begins with a sensation of stiffness and 
some impaired mobility of the joint ; flexion is difficult, while exten- 
sion, on the contrary, is generall}'^ hindered to a less degree. Swelling 
of the joint, which may be proved by comparative measurements, is 
early recognized by the depressions to both sides of the ligamentum 
patella, as also by the knee-joint appearing fuller and larger. The 

case be in its primary stage, the splint alone may be sufficient to overcome the con- 
traction, while in aggravated cases tenotomy may be required. 

Should fluctuation be discovered in the joint, Bauer, Barwell, and others, recom- 
mend evacuation of the pus, either by opening the capsule with a tenotome, allowing 
its exit into surrounding tissues, or the use of a trocar and canula. The latter measure 
seems preferable, inasmuch as by it the fluid may be seen and examined, and the 
diagnosis confirmed as well as the treatment aided. Finally, in the third stage of the 
disease, where there is great deformity from strong and rigid contractions which can- 
not be overcome by counter-extension, etc., aided by chloroform, and there is intense 
suffering from muscular spasms, tenotomy must be resorted to, after which the limb, 
being placed in position, may be retained so by means of the hip-joint splint. Foi 
further details, the student is referred to the standard works on surgery.] 



GENERAL DISEASES OF THE SECRETIONS. 615 

temperature of the part is usually somewhat increased. As the dis- 
ease progresses, the leg gradually becomes contracted upon the thigh, 
and the movements more painful, especially flexure of the limb. 
The pains soon become constant, even vs^ithout any attempts at motion. 
At first they are of a dull character, after a while become more intense 
and sharper, and extend down to the foot, the tumefaction increases, 
generally has a peculiarly-elastic feel, but does not fluctuate ; the in- 
tegument retains its color, and is mostly intense and shining. When 
suppuration begins within the cavity of the joint, and the abscesses 
rapidly increase in size, the integument becomes red, and distinct fluc- 
tuation is felt, more or less plainly, in the degree in which the pus 
reaches the skin ; the pains become so aggravating as to rob the pa- 
tient completely of all rest and comfort. The abscesses burst either 
in the circumference of the joint, or the pus sinks downward along the 
leg, and in some cases makes its appearance in the region of the ankle. 
In addition, abscesses have been observed to break on all parts of the 
leg, most frequently on its anterior surface. The pus, facilitated by 
the position of the extremity, has also been seen to travel for a dis- 
tance upward upon the thigh, and to make its appearance there. 
"S'S^'hen the process is attended by carious destruction of the bones en- 
tering into the formation of the joint, and ulceration of the capsule and 
the contiguous soft parts, dislocation of the bones may likewise ensue 
in this condition, and this may happen especially to the tibia, which 
will present a partial or total luxation from its natural position. 

The process may come to a stand-still, at every stage of the stated 
alteration in the course of the disease, in which, according to the ex- 
tent of the pathological alterations, more or less impairment of motion, 
and of the configxu-ation of the joint, will ensue. In most instances 
there results — when the treatment did not prevent this termination — 
a cure, with union of the Joint ends — anchylosis : in more favorable 
cases, where the treatment was more successful, the result will be the 
formation of fibrinous and ligamentous bands, following inflamma- 
tions which took their issue from the synovial membrane, and Avere 
unattended by any serious destruction of the cartilages — false anchy- 
losis : in the imfavorable, complete bony union of all the bones of the 
joint following carious inflammation of the bones, with exfoliation of 
the cartilages — true anchylosis. 

If the disease goes on without displaying any tendency to abate, 
and enters its last stages, the leg will become oedematous, suppuration 
will be profuse, the general phenomena assume a more and more 
a.arming character, and death ensue either from exhaustion or puru- 
lent infection. 

Therapeutics. — The principles already laid down in the treatment 



616 DISEASES OF CHILDREN. 

of inflammation of the hip-joint are also appHcable here. Of the seri- 
ous surgical operations, amputation of the thigh will claim the main 
consideration ; resection of the knee-joint will hardly ever be practi- 
cable, on account of the extensive osseous surfaces, which will have 
again to undergo suppuration, and the small prospect of recovery 
which will attend this operation. 

Scrofulous Inflammation of the Axkle-Jolnt {Tumor Aldus 
Articuli Pedis, JPodarthrocace). — This disease, which is of tolerably 
frequent occurrence, usually commences by a very moderate, and after 
a while a more intense, growing, fixed pain either on the anterior sur- 
face of the ankle-joint or on one of the lateral regions, seldom embra- 
cing the entire joint. Motion, at first, is but little hindered ; soon, how- 
ever, it becomes so difficult that the foot is dragged along, the patient 
being unable to bring it down flat upon the floor, and every false 
step, every collision with firm objects, even the stepping upon firm 
bodies, stones, etc., induces a painful sensation of the joint. An elastic 
swelling, covered by normal-colored skin, soon manifests itself about 
the ankle-joint, by which the spaces beneath the malleoli become filled 
out, and the entire region of the joint more voluminous. The pain is 
constant, of a dull or tearing character, and radiates over the foot. 

At a further stage of the malady the skin becomes reddened and 
the swelling softer, fluctuation is detected at one or more places, in con- 
sequence of the purulent accumulation either direct from the ankle- 
joint or from an abscess that has originated in its vicinity, and which 
soon communicates with the cavity of the joint. The pains attain to 
their acme before the abscess breaks ; when that has occurred, they 
decline in intensity. Through the fistulous openings, of which quite 
a number are sometimes seen about the joint, the opened cavity 
of the joint may readily be reached with a probe, or the probe may 
encounter carious portions of bone belonging to the tibia or tarsal 
bones, while from it a very badly-smelling discolored pus, which is also 
mixed with crumbly granular pieces of tubercular masses and parti- 
cles of bone, escapes. Tlie fistulous openings are indebted for their 
origin to abscesses that have formed in the soft parts around the 
joint, and which, in most instances, will be found to penetrate clear 
into the diseased cavity of the joint. 

At a further stage, if the disease has gone on unchecked, the foot 
becomes misshapen and deformed, for its anterior part generally ema- 
ciates, the region of the joint thereby appears disproportionately en- 
larged, and, in addition, is drawn upward in consequence of con- 
traction of the tendo Achillis, after the manner of talipes equinus. 
The disease, as a rule, runs a very slow course, with acute and sub- 
acute exacerbations ; sometimes heals with deformity and permanent 



GENERAL DISEASES OF THE SECRETIONS. 61 Y 

impairment of motion, but, under serious disturbances of the gen- 
eral system, from profuse suppuration and exhaustion, may also 
terminate fatally. 

Therapeutics. — Besides amputation of the leg, -which, in this form, 
may come into consideration, it may also be a question about ex- 
secting the carious ankle-joint, if the disease has only involved the 
lower joint-end of the tibia, and the upper surface of the astragalus. 

Scrofulous Inplammation of the Elbow-joint ( Olecranar- 
throcace). — In strumous subjects, the elbow-joint is not infrequently 
the site of inflammation, which generally has its starting-point in the 
synovial membrane, and attacks the bony joint-ends ; sometimes, 
again, it first starts from the spongy portion of the bones entering into 
the formation of the joint. The disease, as a rule, begins with a 
slight degree of difficulty in exercising the joint, and with mild pains ; 
both phenomena gradually become aggravated, while round about the 
joint a swelling forms, which at first is tolerably dense and elastic, 
but, after a while, becomes soft and breaks open at one or more places. 

The forearm is bent more or less upon the upper arm, and has a 
position midway between pronation and supination ; the whole ex- 
tremity not infrequently presents a peculiar appearance, for the fore- 
arm is atrophic, the upper arm also, on account of its inactivity, suffers 
its muscles to become emaciated, while the region of the joint is seen 
to be swollen into a spindle or globular form. The destruction within 
the joint, as a rule, may be easily ascertained by the examination with 
the probe through the sinuses, as these, in most instances, do not form 
any very long tracts, but lead directly to the bone. 

The general phenomena vary in the manner often already de- 
scribed, according as to whether the course has an acute or chronic 
character ; hectic and pyasmic fever less frequently become developed 
from this kind of scrofulous inflammations than from those previously 
described, but, nevertheless, do likewise occur. "V^Tien the disease 
goes on toward recovery, a cure may take place, with more or less 
deformity and anchylosis. Dislocations of some of the bones from 
their normal position do not often occur, even in extensive destruction. 
Most frequently, a luxation of the ulna backward, or a displacement 
of the head of the radius inward, takes place. 

Therapeutics. — Besides amputation of the upper arm, which may 
come into consideration in very violent inflammations of the elbow- 
joint endangering life, resection of the carious bones is yet to be men- 
tioned, Avhich is not infrequently resorted to in exhaustive suppuration 
to save the life of the patient, or to shorten the morbid process in the 
joint. Generally a longitudinal incision, running parallel with the 
inner border of the olecranon, commencing two fingers' width above it, 



618 DISEASES OF CHILDREX. 

and running downward, will be sufficient for the removal of the dis- 
eased bones ; where this does not answ^er, a complicated incision, the 
shape of which depends mostly upon tlie existence of the sinuses, will 
be necessary. In all methods of operation, proper care should be taken 
to preserve the ulnar nerve. 

General Treatment of Tuberculosis and Scrofula. — In the 
great importance which, according to my views, is to be attached to 
the hereditary disposition, as the chief cause, there can be less of a 
question of preventing the outbreak of the cachexia, than of attaining 
a possibly mild, favorable course of the various local manifestations. 

Scrupulous avoidance of aU digestive disturbances, and residence 
in well-ventilated rooms, are the tAvo chief points upon which the phy- 
sician has to insist, in children the progeny of tuberculous parents. 

They should remain for a long time at the breast of a healthy 
wet-nurse, and be weaned with the utmost caution. Subsequently, all 
nutriments which produce flatulence are to be avoided. The chief 
articles of diet in the first ten years should be milk and milk soups, 
beef broths and juicy meat, tender vegetables, and plenty of ripe 
fruit. Potatoes should not be allowed in large quantities ; the bread 
should be well baked. Cliildren should get nothing but water for a 
di'ink. Small quantities of beer can do no harm ; Avine and other 
spirituous liquors, however, should be strictly prohibited. 

Acorn coffee is especially adapted as a drink at breakfast, and 
pure milk is to be substituted for it when the patients are no longer 
disposed to take it readily ; genuine cofiee should not be used under 
any circumstances. 

No departure need be made from this diet, so long as the strumous 
affections, which happen to supervene, are feverless ; when febrile ex- 
citement comes on, the instinct, which in cliildren is even keener than 
in the adult, will forbid it of itself. 

As regards the residence, a sunny sleeping and sitting-room, as 
large as possible, and capable of being thoroughly ventilated, is to be 
urgently recommended. In summer the children should be out the 
entire day in the fresh air ; in winter, at least two hours every day. 
Frequent tepid-warm, and, still better, cold baths and ablutions are 
the best means of protecting the children against colds, and the so- 
frequent bronchial catarrhs. Sea-baths and salt-water spring baths 
are also of especial benefit to scrofulous children. 

In summer they should live in the country ; in winter, in large, 
spacious apartments. The residence in warm climates during the cold 
seasons of the year has, it is true, the great advantage that the chil- 
dren are there able to be much more out in the fresh air. But since 
this change of place has to be carried out every year, if, in the sue- 



GENERAL DISEASES OF THE SECHETIONS. 619 

ceeding years, the children are not to be subjected to the danger of 
suffering decided harm, they thereby become accustomed from their 
earliest youth on to an unsettled, roving hfe, and regard themselves 
as eternal patients. That there is no happy prospect in store for such 
hot-house plants needs scarcely any additional assurance. 

Of the remedial agents, cod-liver oil without doubt deserves the 
first name on the list. It is contraindicated in febrile conditions, in 
anorexia, and in diarrhoea ; the latter condition it is of itself apt to 
induce in the hot summer season. Aside from that, it is taken with 
the greatest advantage for years by all scrofulous, and also well-pro- 
nounced tuberculous children. 

It is best to give it one or two hours after breakfast, in quantities 
of from one-half to one tablespoonful — a little coffee or a small piece 
of sugar is given afterward. On the whole, most children do not re- 
quire to be remunerated at all with any jjarticular delicacies for taking 
the oil, for usually it is not repulsive to them in the least, and they will 
themselves remind the nurse to give it to them if she has once for- 
gotten to do so. It is well to inform the relations, at the very outset of 
the cure, that an improvement can only be derived from years' constant 
use of the remedy, and that it has to be given for many months, even 
though at first no change or no aggravation should have taken place. 

In well-nourished, but, for the most part, strongly-tainted, scrofu- 
lous children, small doses of tincture of iodine, one or two drops, to 
the ounce of the oil, may be added. Still, I would never advise a 
long-continued, internal treatment with iodine. Springs containing 
iodine and bromine, of which Heilbronner stands at the head of the 
list, next Kreuznach, are of decided benefit in scrofulous children 
free from bronchitis, but totally contraindicated in emaciated children 
with suspicious bronchitis. 

If the cod-liver oil is not tolerated, or the child refuses to take it, 
some substitute must be looked for which will take its place. A tea 
made from walnut-leaves seems to be the most advantageous, and of 
w^hich two or three cupfuls should be given daily. A decoction of 
hops, or a calamus infusion, is also relished by some children, but 
many others refuse to take either on account of the intense bitterness. 
To children with excessively-pale lips and mucous membrane, mineral 
waters containing iron, or easily-assimilated preparations of iron, for 
example, ^ martis pomat.,* must be given. 

All exhausting treatment, whether it consists in abstraction of 
blood or emetics, in purgatives, in antimonials or mercurials, induces, 
in all cases, an aggravation of the dyscrasia, and is therefore to be 
entirely avoided. 

* [Malatc of iron.] 



(^20 DISEASES OF CHILDREN. 

Unfortunate, finally, are the efifects which result from surgical 
operations on scrofulous bones. The same diseases of the bones, for 
which the operation was undertaken, usually spring up anew on the 
wounds of the bones, and the process is but little retarded, in spite of 
all the torture and pains. 

(3.) Hereditary Syphilis. — Syphilitic parents beget children, 
who are either born with the signs of the malady, or, at least, pre- 
sent them in the first few months of life. Prognostically, it is of im- 
portance to distinguish whether the children bring with them the de- 
veloped syphilis into the world, or only become aifected with it some 
time thereafter. 

Children, in whom syphilis has broken out in iitero, are mostly de- 
livered prematurely and dead, and surely perish soon after delivery if 
they came into the world with pempliigus vesicles. But the progeny of 
syphilitic parents, born apparently healthy, who only manifest signs of 
inherited syphihs after many weeks or months, very frequently recover 
under an appropriate treatment, and may develop perfectly, without 
any further cachectic troubles. 

Before we enter more minutely into the etiological question, it 
may prove advantageous to first analyze the morbid alterations be- 
longing to syphilis. 

Symptoms. — Inherited syphilis manifests itself: (1), upon the 
skin; (2), upon the mucous membranes; (3), in the subcutaneous 
cellular tissue; (4), in the muscles and bones; and (5), in the inter- 
nal glandular organs. 

(ad 1.) Skin. — Syphihtic eruptions of the skin (the syphilides) 
are divided into (1), maculous axidi squamous ; (2), papulous ; and 
(3), pustulous and bullous. 

To ihe first form 

Roseola syphilitica belongs. By this we understand small spots, 
of the size of lentils up to that of split peas, of a coppery color. They 
appear simultaneously upon large tracts of the surface of the body 
as bright-yellow or yellowish-red spots, primarily without any alter- 
ation of the epidermis of the aifected parts, and without any indura- 
tion or elevation over the parts of the integument that are still sound. 
In time, however, they become slightly elevated, the color turns to 
coppery, and they appear as if ground off, or, in other cases, become 
covered with fine white scales. If the patient is subjected to an anti- 
syphihtic treatment, they wiU disappear entirely, but, if nothing is 
done, they will become more and more infiltrated, the epidermis either 
corrugated or drj^, the crusts begin to exhale serum, and the spots 
covered with yellow scabs. 

On parts of the integument that are constantly soiled with the al 



GENERAL DISEASES OF THE SECRETIONS. 621 

vine discharges, as on the nates, and the posterior surfaces of the thighs 
and extremities, excoriations often form, and finally, also, deep ecthy- 
ma-like ulcers. 

Even the unaffected portions of the skin never preserve the nor- 
mal color and smoothness. They exchange their rose-red color for a 
smoky-grayish one ; this is strikingly seen on the face, and still more 
so on the forehead. The integument in many places becomes wrin- 
kled, in consequence of the emaciation which invariably ensues in 
syphilis. The palms of the hands and soles of the feet seldom re- 
main intact; a serious desquamation soon takes place upon them, 
and, in children who often handle the dirty sugar-teat, deep ulcers 
form on the palms of the hands. This preference of the syphilides 
for the last-mentioned parts of the integument is of great importance 
in the diagnosis, for the other non-syphilitic eruptions spare these 
very parts. 

The second form, papulous, scarcely ever exists by itself, but is 
complicated either with the first or third form, bullous. Syphilitic 
papules (lichen or strophulus syphihtica) are of a brownish color and 
hard, without any red areola, in most instances dispersed, and are 
likewise oftenest found on the palms of the hands and soles of the 
feet. They are not characteristic enough to allow the diagnosis of 
syphilis to be based upon them alone without any additional symp- 
toms. If no treatment is instituted, they will remain unaltered for a 
long time, grow more and more numerous, are destroyed in many 
places by scratching, and then represented by larger or smaller irregular 
ulcers. But, if a proper treatment is carried out, they will complete- 
ly disappear in a short time ; this is explained by the slight morbid 
derangement they had produced. 

The third fonn, bullous, and pustular, is the most mahgnant, and 
occurs only in the very aggravated stages of the cachexia. It is repre- 
sented by 

Pemphigus Syphilitica. — By this we understand yellow, yellow- 
ish-green, or brownish purulent blebs, of the size of a hempseed up 
to that of a bean, surrounded only by a narrow areola. Their con- 
tents are turbid, purulent, of an alkaline reaction. Tliey occur mostly 
in an isolated form, coalesce only on very few places, and these are 
also most surely found upon the palms of the hands and soles of the 
feet. These pustules either collapse after several days, and dry up into 
thin crusts, or they burst, their contents escape, and an intensely-red- 
dened cutis becomes visible after the epidermis has exfoliated. After- 
ward the sore discharges but very little, so that hardly any crusts 
form, and the garments are but little soiled. It is not possible for 
deep ulcerations to form, for the simple reason that the subjects 



622 DISEASES OF CHILDREN. 

do not live long enough for that purpose, but collajDse rapidly, and per- 
ish, "without any additional sickness, under weakness and exhaustion. 

The prognosis, in this bullous exanthema, may be put down as 
fatal Avith the utmost certainty. Children who bring the developed 
pustules with them into the world die in the first few days after de- 
livery ; but, when they acquire them a little later, between the third 
and eighth day of life, they may live for a few weeks, but ultimate- 
ly die almost unexceptionally. That form of congenital syphilis, 
which, according to ZeissVs extensive experience, almost entirely 
manifests itself in the form of pempliigus, is invariably fatal. 

It is a remarkable fact that syphilis, in the great majority of these 
cases, descends from the father, and that the most careful examina- 
tion of the mother leads to no positive results, so that the connection 
between these exanthemata and syphilis has often been doubted. 
The doubts have mainly arisen in lying-in-houses, where the afi"ected 
fathers very naturally could seldom be seen, while, in private practice, 
the previous and present state of health of the father can readily be 
ascertained. In the latter case it becomes apparent that the father 
invariably suffers, or at least had suffered, from secondary syphilis. It 
has often been observed that, after the father had subjected himself 
to a thorough antisyphilitic treatment, the children then generated 
come into the world normal, without any sign of syphilis whatever, 
and subsequently also remained well. 

Besides these pathognomonic pemphigus pustules, there is yet a 
pustular eruption which occurs at a later period in syphilitic chil- 
dren, but these pustules are situated upon a red, hard base, and, 
after they burst, leave behind deep lardaceous ulcers (ecthyma pus- 
tules). 

The cutaneous ulcers and rhagades, which only break out after 
birth, are the most characteristic lesions . of syphilis ; they occur by 
special preference at the angles of the mouth, on the margins of the 
lips, and around the anus and genitals. The ulcers on the lips are 
flat, have a yellow, but slightly -indurated base, and are strictly con- 
fined at first to the red margin which hems the lip. Not till after 
some time do they grow beyond their original limits, and involve the 
adjacent integument, particularly the lower lip, where the epidermis 
is softened, by the food and sugar-teat. 

By rhagades, cracks, fissures of the lips in the direction of the nat- 
ural cutaneous folds, are understood. They sometimes originate in 
perfectly-healthy lijDs, generally, however, the ulcers just described 
are present, from the crusts of which the lips become brittle, and, when 
they are much stretched, as they necessarily must be everv time the 



GENERAL DISEASES OF THE SECRETIONS, 623 

child cries, it causes them to crack and break. The little fissure is 
next infected by the pus from the ulcers, and tolerably deep, yellow 
erosions result, which bleed freely every time the lip is stretched, and 
for the same reason also heal extremely slowly. 

The fissures are also met with at the nares, though less frequently 
than about the mouth, as also about the anus and vulva in girls, and 
occasionally also at the angles of the eye. Those of the lips have an 
additional particular importance, namely, by them a syphilitic nursling 
may most surely and directly infect a healthy wet-nurse. 

Finally, as regards the cutaneous secretion, badly-smelling perspi- 
rations over the entire body, especially on the head, occasionally occur 
in syphilitic children. They also disappear as soon as the cachexia is 
eradicated from the system. 

(ad 2.) Mucous Membranes. — Swelling of the nasal inucous mem- 
brane is the first manifestation of hereditary syiDhilis, and does not ap- 
pear for some weeks after the delivery. Children thus affected breathe 
through the open mouth, and snore while nursing. No morbid altera- 
tions are to be observed on the external surfaces of the nose, but the 
mucous membrane appears reddened and turaefied. A purulent dis- 
charge, coryza syphihtica, sets in after this swelling has existed for 
several days, the pus at first is muculent, and subsequently becomes 
sanguinolent, ichorous, eroding the upper hp over which it flows down. 
The spreading serpiginous ulcers which soon form may finally attack 
the bone, and cause necrosis and exfoliation of the vomer, the turbi- 
nated, and the ethmoid bones. When the subjects surmount such an 
intense syphilis, the nose at least will be destroyed, and the face dis- 
figured for life. 

The same flat, shallow ulcers originate upon the inucous membrane 
o£ the mouth, and upon the tongue^ as on the margins of the Hps ; 
they never penetrate deeply, and readily cicatrize, if a proper treatment 
has been instituted. 

The fissures and ulcers about the anus, on the vulva and prepuce, 
have already been spoken of. Leucorrhoea and ulceration of the 
vagina occur tolerably often. Otorrhoea and ophthalmoblennorrhoea 
in syphihtic children dififer only by their great intensity from the non- 
syphilitic. In this ophthalmoblennorrhoea both cornece soften in the 
shortest time, and the process terminates extremely unfortunately, with 
phthisis bulbi. 

(ad 3.) Subcutaneous Cellular Tissue. — In many syphilitic chil- 
dren small abscesses form in the subcutaneous cellular tissue, which 
have no connection with the lymphatic glands. Whether the ab- 
scesses are opened with the lancet, or whether they break si^ontane- 
ously, the orifices, in all instances, become ulcerated, and cicatrize 



Q24: DISEASES OF CHILDREN. 

only after a long time, with intensely-colored puckerings. Ulcera- 
tion of the nails (onychia) is very often observed on many fingers 
and toes at the same time. These processes are also very tedious, 
especially when the fingers come a great deal in contact with the 
sugar-teat ; the new nail then becomes rough, uneven, and mis- 
shaped. 

The lymphatic glands, in the neighborhood of syphilitic ulcers, 
do indeed swell up consecutively ; they seldom, however, pass over 
into suppuration. In general, it may be said that the lymphatic 
glandular apparatus of children is much less affected by syphilis 
than by scrofula and tuberculosis. 

(ad 4.) 3Iuscles and Hones. — In very severe syphilis, which de- 
velops itself several weeks after birth, paralysis of the upper, less 
frequently of the lower, extremities occurs. These paralyses do not 
always extend over an entire extremity, nor are they always com- 
plete, for often a slight capacity of exercising some of the muscular 
groups remains behind. 

The bones participate in hereditary syphilis very rarely only. 
Congenital fragilitas ossium, in which all the tubular bones may be 
broken into fragments with the least amount of power, and which 
naturally is only met with in still-born, or in children dying soon 
after delivery, has been claimed to be connected with syphilis of the 
parents. 

This process, on the whole, is extremely rare, and, in the cases 
so far observed, the existence of syphilis was not by any means dem- 
onstrated in a satisfactory manner. 

Periostitis and necrosis of some portions of the bones, a very 
usual process in secondary syphilis of the adult, occurs but very sel- 
dom in hereditary syphilis of the new-born child. 

(ad 5.) Glandular Internal Organs. — Abscesses in the thymus 
glands, which have already been treated on page 233, are very much 
doubted as to being syphilitic, for the physiological cavities, which 
form in the atrophy and absorption of this gland, can scarcely be 
differentiated from abscesses. 

In still-bom children, the progeny of syphilitic parents, true ab- 
scesses are observed in the thymus gland in some rare instances ; it 
is, however, necessary to guard against the possibility of mistaking 
the physiological cavities which contain a white fluid, and which oc- 
cur in all children, for abscesses. The contents of the former always 
react acid, those of the latter, like pus, alkaline. In general, it should 
be observed that, in most children who die from hereditary syphilis, 7io 
purulent cavities of this kind can be found. I have already dissected 
at least a dozen such children, but only once found a cavity which 



GENERAL DISEASES OF THE SECRETIONS. 625 

resembled more an abscess than a physiological cavern ; the chemical 
test was unfortunately omitted. Mednar has also observed cystic 
formations in the thymus of syphilitic children. In some cases, he 
found cysts of the size of beans, filled with clear, yellowish fluid, and, 
in others, the whole lobes were converted into two large, yellow 
cysts. 

The morbid alterations of the Hver have already been described on 
page ]82. In the lungs, spleen, and kidneys, gummy tumors of a 
specific character have been found. Most of the children thus aifect- 
ed come into the world with a bullous eruption, and invariably die in 
a few days. 

CouESE AND TEEMiNATiGisr. — As soou as the first signs of he- 
reditary syphilis have appeared, which commonly happens, with 
the exception of congenital pemphigus, in from one to six months 
after delivery, the child begins to lose flesh, becomes restless, and 
soon acquires the characteristic, smoky appearance of the skin. Chil- 
dren, who are about to be brought up by hand, succumb usually to 
anemia, or to a supervening intestinal catarrh. Children at the 
breast, under a proper treatment, recover tolerably often. The later 
the syphilis comes on, the more favorable the prognosis ; the earlier, 
the more unfavorable. 

Etiology. — In the great majority of cases hereditary syphilis de- 
scends from the father, not from the mother. If the mother is afflict- 
ed with secondary syphilis, the pregnancy will hardly ever go on to 
its natural conclusion ; an abortion, or, at least, a premature delivery, 
will take place. This, in fact, happens also, although less frequently, 
in secondary syphilis of the father ; the pregnancy here usually ter- 
minates normally, but the child comes into the world either with 
pemphigus syphilitica, or manifests the above delineated signs of he- 
reditary syphilis in the first six months of life. 

When the father suffers from secondary syphilis, the mother may 
remain uncontaminated, and nevertheless give birth to a syphilitic 
child ; conception and delivery of such children may even be repeated 
several times without the mother becoming infected in the least. 
This often-confirmed fact is all the more remarkable, as the foetal 
blood communicates directly with the maternal, and the fostus ac- 
quires syphilitic pemphigus in utero. 

Secondary syphihs descends only from the mother when she be- 
comes infected with primary before or during pregnancy, and subse- 
quently manifests the secondary symptoms. When the mother only 
becomes primarily infected during the last three months of gestation, 
the offspring will remain uncontaminated. It seems very improbable 
that a healthy child could become infected from primary ulcers on the 



(j26 DISEASES OF CHILDREN. 

labia, with which it may come in contact during the act of delivery. 
The children are covered with a thick layer of vernix caseosa, and 
have suffered no loss of substance on any part of the body ; in this 
case they would also have to have a primary chancre before the 
secondary eruption breaks out, a condition that is scarcely ever ob- 
served. 

There is another remarkable fact, namely, that a child, who in- 
herited its cachexia entirely from the father, the mother being sound, 
will never inoculate its own mother, while a healthy wet-nurse, who 
undertakes to suckle such a child, becomes infected as a rule. There 
results from this the therapeutically important principle that a syphi- 
litic child may readily enough be allowed to be suckled by its own 
mother, but never by a wet-nurse, for the latter, if she should happen 
to become inoculated, may justly hold the physician responsible. 

The manner in which a syiDhilitic nursling infects a healthy wet- 
nurse is not always demonstrable. The simplest manner in which the 
inoculation may take place is by the ulcers on the lips of the nursling 
coming in contact with a sore on the nipple of the breast of the wet- 
nurse. Occasionally it is observed that the breasts of the wet-nurse 
remain uninjured, and symptoms of constitutional syphilis come on 
notwithstanding. Conversely, it also happens, that a syphilitic wet- 
nurse transmits syphilis upon a healthy cliild, without the nipples of 
her breasts having been diseased. There is no necessity at all to 
resort to a transmission by the milk to explain these cases. Contact 
of the child with the mouth of the wet-nurse, or with her fingers, which 
shortly before had touched sj^ohilitic parts, seems to be the more likely 
cause. 

It is not absolutely the rule that a father who is affected with 
secondary syphilis should always beget syjihilitic children. A consid- 
erable number of children remain free from all kinds of cachexias, while 
the fathers are well known to be strongly tainted. The children of a 
father are least susceptible, whose syphilis is already very inveterate, 
has left the skin and mucous membranes, and has become located as 
tertiary s3qDhilis in the bones. 

Treatment. — Mercury acts extremely quickly and beneficially in 
syphilis of small children, and, in fact, best when applied in an ender- 
mic manner. For a number of years past I have ceased giving mer- 
Icurial preparations internally — calomel and mercurius solubiHs Hahne- 
manni* are most frequently used in this manner. I order 3ss — 3j 
of blue mass to be actively rubbed in every day upon portions of 
sound skin, of which enough may always be found in every case. 
When the ointment is rubbed in, in the evening, a bath may be given 

* [Black oxide of mercury.] 



GENEKAL DISEASES OF THE SECRETIONS. Q2T 

on the next morning without any detriment to the cure, and after that 
the inunction is repeated. 

The local ulcers are best treated by the application of small com- 
presses, wherever they can be applied — dipped in chamomile tea ; the 
fissures and ulcers on the lips improve Adsibly by touching them sev- 
eral times with nitrate of silver. Baths, with corrosive sublimate, of 
which 3 i — 3 i is advised to be used in every bath, are expensive and 
dangerous to the child and its attendants, and, where the treatment is 
judiciously carried out with in\, nctions, may be dispensed with. The 
internal use of iodine can seldom be continued long enough in small 
children, for derangements of the digestion and a quicker progress of 
the marasmus are thereby frequently induced. 

The diet should be as nutritious as possible. Children who are 
nurtured at their own mothers' breasts have the best chance of recov- 
ering. In artificially-fed children, the chief task will be the avoidance 
of diarrhoea, which may be attained by a carefully-prepared diet and 
demulcent drinks. When we succeed in this, the children will sur- 
mount the syphilis. 



11^ D E X. 



A. 

Abdomen, Examination of the, 34. 

" Shape of, in acute Hydrocephalus, 282. 

Abdominal Pains in acute Hydrocephalus, 282. 
" " TyphusFever, 4S4. 

Abscesses, retropharyng-eal, 116; IJokai's Classi- 
fication of, 116 ; Treatment of, 117. 

Abscesses, as a Sequel of Small-pox, 482. 

Absinthe, Taste of, in Milk, 39. 

Acardia, 193. 

Acephalia, 307. 

Acquired Atelectasis of the Lungs, 250. 
'• Hydrocephalus, 298. 
" Paraphimosis, 395. 
" Rupture of umbihcal King, 65. 

Actual Cautery in Tetanus, 70. 

Acute Hydrocephalus, 271. 

Adhassio Lingu*, 89. 

Adipose Tumors, 639. 

Adventitious Growths in the Nose, 217; Treat- 
ment, 218. 

Affection, pneumo-g'astrite-pituiteuse, 513. 

Aggregated Tubercles, 567. 

Air, Inflation of, in Asphyxia, 56. 

Albuminuria, as a Complication of Diphtheria, 447. 

Alcoholic Drinks, Influence of, on Milk, 41. 

Alterations of Mesenteric Glands, 192. 

Amaurosis, as a Complication of Diphtheria, 448. 

Anal Fissure. 165. 

Analysis of Milk, 37. 

Anatomo-pathological Remarks upon the infantile 
Organism. 1. 

Angina Hippocratis, 600. 

" Laryngia Exudatoria, 453. 
" Stridula. 223. 

" Tonsillaris, 113 ; Symptoms of; 113 ; Treat- 
ment of, 114. 

Ankle-joint, scrofulous Inflammation of, 616; 
Treatment of, 017. 

Anterior Fontanel, Size of, 8" Enlargement of, in 
the Trimesters, i). 

Antiepileptic, specific Remedies, .347. 

Antipyrine, 496. 

Anus, E.xaraination of, 24 ; Malformations of, 1G9 ; 
Constrii.'tion of, 169 ; Occlusion of, 169 ; Treat- 
ment of, 171. 

Aphtha}, 99. 

Apnrea Infantum, 222. 

Appetite, Condition of, in acute Hydrocephalus, 

Arterial Telancieetasis, 210. 

Arteriae Unibiliciles. 2. 

Arteries and Veins, 210. 

Arteritis and Phlebitis umbilicnies, 62. 

Arthrocace, scrofulous, 603. 

41 



Artificial Feeding, 43. 

•' Respiration, in Atelectasis Pulmonum, 
56. 
Ascaris Lumbricoides. 175. 
Ascites, 190; Pathology of, 190; Symptoms of, 

190; Treatment of, 191. 
Asphyxia Neonatorum, 54; Causes of, 55; Pathol- 
ogy of, 54 ; Course of, 54 ; Treatment of, 56. 
Assimilative Functions, Condition of, in Typhus 

Fever, 482. 
Asthma Thymico Cyanoticum, 222. 

" Thymicum Koppii, 227. 
Atelectasis Pulmonum. congenital, 57; Symptoms 

of, 57 ; Etiology of, 57 ; Treatment of, 57. 
Atelectasis Pulmonum, acquired, 250; Pathology 

of, 250 ; Symptoms of, 251 ; Prognosis of, 253 ; 

Treatment of, 253. 
Atresia Pupillares Congenita, 357. 

"■ Meatus Auditorius, 359. 

" Urethrae, 393. 
Aura of Epilepsy, 341. 
Auricles, Absence of the, 357. 

" Defect of the, 357. 
Auricula Adpressa, 359. 
" Ausbleiben," 223. 
Auscultation, 23. 



B. 



Balanitis, 394; Treatment of, 395. 

Ballismus. 329. 

Bathing of Children, 52. 

Bed-sores in Tvphus Fever. 491. 

Bladder, Malformations of the, 380; total Ab- 
sence of the, 3S0 ; Fissure of the, 881; Pro- 
lapsus of the. 381 ; Treatment of, 3S3 ; Earl's 
Apparatus in. 883. 

Bladder, Cloacas of the, 8S3. 
Catarrh of the, 383. 

Blanchet, 99. 

Blauerhusten, 513. 

Blennorrhceal Inflammation of the Conjunctiva in 
New-hnrn, 76. 

Blennorrhceal Inflammation of the Conjunctiva in 
difficult Dentition. 110. 

Blennorrhoea and Ulceration of the Navel, 63; 
Treatment of, 63. 

Blennorrhoea Neonatorum. 76. 

Blepharospasmus, 582 ; Treatment of, 582. 

Blood-corpuscles in Milk, 35, 

Bloody Tumor of the Head, 59. 

Bodily and mental Ilyciene of Epileptics, 351. 

Bones, Gangrene of .596; scrofiilou.s Inflamma- 
tion of. 5^7; syi)liililic effect of, 624. 

Botbriocephalus Latus, 174. 



630 



INDEX. 



Brain, cong-enital Hernia of the, 307; excessive 
Growth of, 308. 

Brain, congenital Malformations of, 307. 

Sclerosis of the, 304; Treatment of, 304; 
Neoplasms of the, 304 ; Carcinoma of, 
306 ; EntozosB of, 306. 
" Tubercle of. 305; Symptoms of, 307. 

Breasts, Inflammation of the, S3. 

Bright's Disease of the Kidney, 374; Pathology 
of, 374; French's Division of, 874; Symp- 
toms of, 375 ; Treatment of, 878. 

Bronchial Catarrh, 234. 

" •' in difficult Dentition, 100. 

" Glands, Tuberculosis of the, 565. 

Bronchitis, 234 ; Pathology of, '234 ; Symptoms of, 
285; Expectoration in, 236; Percussion in, 
236; Palpation in, 237; Auscultation in, 237; 
Kespiration in, 238; Duration of, 239 ; Etiology 
of, 239 ; as a Complication of Measles, 422 ; of 
Typhus Fever, 492; of Diphtheria, 448; Treat- 
ment of, 240. 

Broncho-cephalite, 513. 

Bulimia, 128 ; Treatment of, 124. 

Burns, 541 ; Treatment of, 541. 

Butter, Amount of, in Milk, according to Cheva- 
lier and Henry, 84. 

Butter, Amount of, in Milk, according to Clemen 
and Scherer, 35. 

Butter, Amount of, in Milk, according to Simon, 
B4. 



Cachexia, scrofulous. 574. 
" tuberculous, 560. 

Caducus. 341. 

Calculi, renal, 379. 

" vesical, 389; 8\Tnptoms of, 890; Course 
of, 890 ; Treatment of, 391. 

Cancer Aquaticus, 97. 

Caput Succedaneum, 60. 

Carbonate of Soda, the Addition of, to Cow's 
Milk, 45. 

Care of Children, 52. 

Navel at first Dressing, 52, 64. 

Caries, scrofulous, 594 ; C. Centralis, 594 ; C. Pro- 
funda, 594; C. Peripherica, 594 ; C. Superflcia- 
lis, 594; C. Partialis, 594; C. Totalis, C. Ne- 
crotica, 594 ; Treatment of, 594. 

Carrot Broth in artificial Feeding, 50. 

Casein in Milk, Amount of, 86. 

Catalepsis Pulmonum, 222. 

Cataract, congenital, 357. 

Cataracta Nuclearis, 857. 

Catarrh, 215. 

" convulsif, 513. 

Catarrhal Inflammation of the Intestines, 146; 
Causes, 147 ; Treatment, 150. 

Catarrhal Inflammation of the Mucous Membrane 
of the Mouth, 91. 

Catarrhus, Auris Mediae, 864. 

'■ Bronchialis Acutus et Chronicus, 234. 
" Ventriculi, 186. 

Cellular Tissues, Abscesses of the, in Typhus Fe- 
ver, 491. 

Cephalaematoma, 59 ; C. Subpericranium, 59 ; C. 
Subapoueuroticum, 60 ; Symptoms of, 60 ; 
Etiology of, CO ; Treatment of, 61. 

Cerebro-Spinal Meningitis, 497 ; Causes, 498 ; 
Pathology, 499; Symptoms, 500; Treatment, 
603 

Chafing, 535; Treatment, 585. 

Chest, Au.scultation of the, 22; Inspection of the, 
18 ; Palpation of the, 28 ; Percussion of the, 
19. 

Chicken-pox, 439. 

Chilblain, 542. 

Children, Care of, 52. 

" General Rules for the Examination of, 
14. 
Growth of, 7, 



Children, Nursing of, 28. 
" Weaning of, 42. 
Chin-cough, 518. 
Chloroform in Tetanus, 70. 
Cholera Asiatica, 505 ; Meyer's Observation on 
the Pulse in, 507; Respiration, Alteration of 
the, in, 508; Intestinal Mucous Membrane, 
Derangements of the, in, 508; Circulation, Al- 
teration of the, in, 509 ; Kidneys, Morbid Al- 
terations, etc., Alterations of, in, 509; Pathol- 
ogy of, 509 ; Treatment of, 509. 
Chorea Major, or Germanorum, 838; Symptoms 
of, 838; Prognosis of, 338; Treatment of, o40. 
Chorea Minor, 329 ; Symptoms of, 329; Etiology 
of, 332 ; Influence of the Sex in, 333 ; Relation 
of, to Rheumatism, 333 ; Diagnosis and Prog- 
nosis of, 834 ; Treatment of, 384. 
Chorea Electrica of DuHni, Description of, 384. 
Chronology of Typhus Fever, 481. 
Cleft Palate, 84 ; difficult Nursing in. S5 ; oblique 
Position of the Teeth in. 86 ; indistinct Speech 
in, 86; Treatment of, 86. 
Cloaca- of the Bladder, 383. 
Clown's Disease, 526. 
Coagulable Fibrin in Milk, 35. 
Coated Tongue, Significance of, in Children, 105. 
Colic, 127; Treatment, 130. 
Coloboma Iridis, 356. 

" of the upper Eyelid, 356. 

Colostrum Corpuscles, 34. 
Combustio, 541. 
Congelatio, 542. 

Congenital Anomalies of the Heart, 193. 
" Anomalies of the Liver, 186. 

" Atelectasis of the Lungs, 57. 

" Closure of the Meatus Urinarius, 393. 

" Fistulaof the Neck, 119. 

" Hernia of the Brain, 802. 

" Malformations of the Brain, 303. 

" Nsevus, 539. 

" Paraphimosis, 393. 

" Phimosis, 392. 

" Rupture of the Cord, 65. 

Congestive or Petechial Fever, 497. 
Conjimctivitis Blennorrha-a Neonatorum, 76 ; 
Arlt's Division of, 76; Course 
and Complications of, 76; 
Causes of, 79; Prognosis of, 
78; Treatment of, 78; Pro- 
phylactic, 78; Local, 79; Cold 
in the, 80. 
" Blennorrhoea in difficult Denti- 

tion, 110. 
" Scrofulosa, 581. 

Constipation, 184 ; Causes of, 134 ; Treatment of, 
135. 
" in acute Hydrocephalus, 277. 

" of the Wet-nurse, 41. 

Constriction of the Anus, 172. 
'' " Mouth, 87. 

" " Rectum, 172. 

Convulsions, 315 ; Causes of, 318; idiopathic, 318; 
deuteropathlc, 318; In Dentition, 
819; at the breaking out of an 
acute Fever, 819; Course, Ter- 
mination, and Prognosis of, 320 ; 
Treatment of 320. 
" in aeute Hydrocephalus, 284. 

" difficult Dentition, 106. 

Coqueluche, 513. 
Corps granuleux, 34. 

Coryza, 215; Etiology of, 216; Treatment of, 216. 
Coryza Syphilitica, 623. 
" Cough," the, in Children, 28. 
Cough, nocturnal, 261. 

Countenance. Expressions of the, in Disease, 15. 
Coxitis Scrofulosa, Coxarthrocaee, Coxalgia, 608. 
Cramps, 315. 
Craniotabes, 549. 

" Relations of, to Spasmus Glottldis, 

226. 



INDEX. 



631 



Cream, Addition of, to Milk, 49. 

Croup, 463 ; Symptoms of, 455 ; ScMautmann's 
Explanation of the Dyspnoea in, 459; Occur- 
rence and Course of, 460 ; Eelapses in, 461 ; 
Prognosis of, 462; Treatment of, 462; Luzin- 
sky's Method, 466; Bretonneau's Cauteriza- 
tions in, 465; Jurin's, 466 ; Goelis's, 466; Hufe- 
land's, 466; Tracheotomy in, 467; Bouchut's 
Observation on, 467 ; Method of performing-, 
468 ; Hsemorrhage in, 468 ; Syncope in, 468 ; 
Goelis'8 Remarks on, 469. 

" Cry," the, of Children, 26. 

Cryptorchidia, 398 ; Von Ammon, Observation on, 
399. 

Cyclopia, 856. 

Cutaneous Eruptions in difficult Dentition, 107; 
Eczema and Impetigo, 108; Lichen and Por- 
rigo, lOS; Urticaria, 108; Treatment of, 109. 

Cynanche Tonsillaris, 113. 
" Tracheal is, 453. 

Cystitis, 883; Pathology of, 383; Symptoms of, 
388; Treatment of, 884. 

Cysts, renal. 380. 
•' syphilitic, 624. 



D. 



Defectus Auriculae, 358. 

" Linguae, 88. 
Dentition, Difficulties of, 106 ; Fever in, 106 ; 

Convulsions in, 106, 819 ; Treatment of, 107. 
Deuteropathic Convulsions, 318. 
Diarrhcea, 131 ; D. Ablactatorum, 132; D. Sim- 
plex, 132. 
Diet of Wet-nurses, Influence of, on the Milk, 37. 
Diet and Hygiene of Wet-nurses, 42. 
Difference between Human and Cow's Milk, 34. 
Differential Diagnosis of Measles and Scarlatina, 

425. 
Digestion, difficult, 121. 
Digestive Apparatus, Diseases of the, 84. 
Diphtheria of the Female Genitals, 476; Treat- 
ment of, 477. 
" as a Sequel of Measles, 422. 

" of the Mouth, 446 ; Symptoms of, 

446; Albuminuria as a Complica- 
tion of, 447 ; Bronchitis and Pneu- 
monia, 448; Myocarditis, 448; in- 
testinal Catarrh, 448; Paralysis, 
448; Amaurosis, 448; Pathology 
of, 449 ; Treatment of, 449. 
Diphtheritic Croup, 453 ; Pathology oi, 453 ; 

Symptoms of, 455 ; Treatment, 462. 
Diseases of the Mind, 353. 
Diseases originating in consequence of Delivery, 

54. 
Double Limbs, 514. 
Dropsical Effusion into the peritoneal Sac, 190; 

Treatment, 191. 
Dropsy of the Pericardium. 209. 
Ductus Arteriosus Botalii, 2, 195. 

" Venosus Arantii, 1. 
Dura Mater, 212. 

Dura Mater, Thrombi in Sinuses of, 210. 
Dyscrasiac Pleurisy, 263. 
Dysentery. 157 ; Symptoms of, 157 ; Pathology of, 

159 ; Treatment of, 1 60. 
Dyspepsia, 121 ; Bamberger's Classification of, 
121 ; Treatment of, 122. 



E. 



Ears, Absence of the, 3.59. 

" Foreign Bodies in the, 870 ; Treatment of, 
871. 

" Scrofula, Disease of, 585. 
Earl's .Vppar.itus, 383. 
Eburneatio, .')4s. 
Eclampsia Infantum, 815. 



Ecthyma, scrofulous, 577 ; Treatment of, 677. 

Ectopia Ani, 172. 

Eczema, Eruption of, in difficult Dentition, 108. 
" Impetiginodes, 577. 
" Eubrum, 576; Treatment of, 577. 

Elbow-joint, scrofulous Inflammation of, 617; 
Treatment of, 617. 

Emphysema of the Lungs, 258; Pathology of, 
254 ; interlobular, 256; Symptoms of, 255. 

Empyema, 263. 

Encephalitis, 308. 

Encephalocele, 802 ; Treatment of, 303. 

Enfants Arrieres, 353. 

English Disease, 544. 

Endocarditis, 199; Pathology of, 201; Symptoms 
of, 200 ; Treatment of; 208. 

Endostitis, 589. 

Enteritis Folliculosa, 153; Pathology of, 153; 
Symptoms of, 154 ; Treatment of, 156. 

Entero-cephalopysa, 271. 

Enthelminthes, 172. 

EntozoEB, 172; Symptoms of, 177; local, 177; 
general and reflex Phenomena of, 178; 
Diagnosis of, 179 ; Treatment of, 179. 
" of the Brain, 306. 

Enuresis, 885; Treatment of, 386. 

Epicanthus, 355. 

Epidemic, cerebro-spinal Fever, 497. 

Epilepsy, 341 ; Symptoms of, 341 ; Course of, 
344; Termination of, 844; Causes of, 344; 
hereditary Nature of. 345; post-mortem Ap- 
pearances in, 846 ; Diagnosis of, 847 ; Treat- 
ment of, 347. 

Epispadia, 393. 

Epistaxis, 213; Etiology, 213 ; SjTnptoms of, 214; 
Treatment, 214. 

Epithelium-cells in MOk, 84. 

Erectile Tumors, 210; Pathology of, 211; Treat- 
ment of; 211. 

Erysipelas, 443 ; Causes of, 444 ; Treatment of, 
444. 

Erythema Neonatorum, 534; Symptoms, 534; 
Etiology, 534; Treatment of, 535. 

Eselhusten, 513. 

Essential Paralysis, 328. 

Ethereal Oils, the Odor of, in Milk, 89. 

Exomphalus, 65. 

Expectoration in Pulmonary Tuberculosis, 666, 
571. 

Expression of Countenance in Child, 15. 

Extremities, Rachitis of the, 554. 

" Position of, at first Dressing, 51. 

Eye, Scrofulous Affection of the, 580. 
" Diseases of the, as a Complication of Small- 
pox, 432. 

Eyeball, Malformations of the, 356. 



F. 



Face, Color of the, in Tuberculosis, 560. 
Facial Erysipelas as a Complication of Typhus 
Fever, 482. 
" Paralysis, 328. 
Falling Sickness, 341. 
Fallsucht, 341. 
Fames Caniua, 128. 
Fat, the, of Milk, 85. 
Fat Scabies, 53S. 

Fatty Liver, 183 ; Treatment, 185. 
Fatty Tumors. 640. 
Febris Hydrocephalica, 272. 

" Intermittens, 580. 
Feeding, artificial, 44. 

" of the Child in the second Tear, 51. 
Female Genitals, Gangrene of the, 476 ; Treat- 
ment of, 477. 
" " Catarrh of, 404. 

" " Diphtheria of the, 476 ; Treat- 

ment of, 477. 
" " Malformations of the, 402. 



632 



INDEX. 



Fevers in difficult Dentition, 116. 

Fette Kriitze, 552. 

Fibrine, coagulable, in Milk, 34. 

First Dressing of tlie New-born, 52. 

Fissura Ani, 165 ; Treatment of, 166. 

Fistula Coli congenita, 119 ; Treatment of, 120. 

Fits, 341. 

Flatulence, 127; Symptoms of, 128; Treatment 
of, 129. 

Fluctuation, Method of ascertaining, 190. 

Fluor Albus. 4U4. 

Flu.x, 15" ; Treatment, 160. 

Fontanel, Enlargement of the, 8; Elsasser's Meth- 
od of measuring the, 8. 
" Average Size of the, in the Trimesters, 
9. 

Food, Nestle's, 49. 

Foramen ov.ile, 2. 

Foreign Bodies In the Ear, 370; Treatment of, 
371. 

Foreign Bodies in the Nose, 218; Treatment of, 
219. 

Forflcula Auricula, 435. 

Freiwilliges Hinken, 605. 

Fraisen, the, 320. 

Frost-bite, 512 ; Treatment of, 543. 

Functional Disturbances in acquired Hydroceph- 
alus, 300. 

Fungus Articuli, 603. 

" Umbilicalis, 64; Treatment of, 64. 

Furunculosis, 536 ; Treatment of, 536. 

" as a Sequel ol Small-pox, 432. 

" in Typhus Fever, 491. 



G. 

Galactometer. Method of using the, 35. 

Gangrene of Navel, 63. 
of Bone, 596. 

Gangriena Pulmonum, 259; Pathology of, 259. 
diffused, 260; circumscribed, 260; Symptoms 
of. 261 ; Treatment of, 261. 

Garlic. Odor of, in Milk, 39. 

Gastric mucous Membranes, hiemorrhagic Ero- 
sions of the, 140. 

Gastric mucous Membranes, catarrhalic Inflam- 
mation of the, 136. 

Gastritis Catarrhalis, 136; Symptoms of, 136; 
Treatment of, 137. 

Gastritis Folliculosa, 137. 

Gastromal.icia, 141. 

Gefiiss-Nabel, 66. 

General Growth of Children, 7. 

Genitals. Examination of the, 26. 

Glandular Internal Organs, syphilitic Affections 
of the. 625. 

Gonalgia, 614. 

Gonarthroc.ace. 614. 

Great St. Vitus's Dance, 333 ; Treatment, 340. 



H. 



Hsemoptoic pulmonary Infarction, 253 ; Patholo- 
gy of, 258; Symptoms of, 259. 

Hiemoptvsis, 257 ; Varieties of, 257 ; in tubercu- 
lous Children, 258 ; Treatment of 258. 

Hemorrhagic Erosions of gastric mucous Mem- 
brane, 140. 

Hcemorrhage from the Lungs. 257. 

of the Navel. 64 ; Treatment of, 65. 
" in Tracheotomy, 468. 

Hiemorrhagia Pulmonum, 258. 

" VaginiE, 406 ; Treatment of, 407. 

Hard Cataract, 357. 

Hare- Lip. 84; difficult Nursing in, 85 ; Malposi- 
tion of the Teeth in, 81 ; indistinct Speech in, 
86 ; Treatment of, 86. 

Hauttalg, 5. 



Headache in acute Hydrocephalus, 281. 

Head and nervous S3'mptoms in Typhus Fever, 
482. 

Hearing, Condition of the, in acute Hydrocepha- 
lus, 282. 

Hearing, Malformation of Organs of, 358. 

Heart, congenital AnomaUes of the. 192 : Absence 
of the, 193 ; abnormal Situation of the, 193 
abnormal Shape and Size of the, 193; abnor 
nial Formation of individual Parts of, 194 
Symptoms of, 196; Treatment of, 197. 

Hectic Fever in Tuberculosis, 571. 

Helminthiasis, 11'^. 

Henle'8 Milk Test, 34. 

Hepar Adiposum, 184. 

Hernia Inguinalis, 163; Varieties and Complica- 
tions of, 164 ; Treatment of, 165. 

Hernia Umbilicalis, 65 ; Treatment of, 66. 

Hiatus Spinalis Congenitus, 312. 

Hip Disease, 60S. 

Hip-joint, scrofulous Inflammation of the, 608 ; 
Treatment of, 615. 

" Hottentot's Apron," 403. 

Hydrocele, 399 ; Varieties of, 400 ; Treatment of, 
402. 

Hydrocephalic Cry, 288. 

Hydrocephalic Exudation, Composition of the, 
272. 

Hydrocephaloid Disease, 295 ; Symptoms of, 295 ; 
post-mortem appearances in", 296; Treatment 
of, 297. 

Hydrocephalus, acute, internal, 271 ; Pathology 
of, 272 ; O. Schmidt's chemical Analysis of 
the Effusion in. 273; Symptmns of, 273; 
Bouchut's stadial Division of, 274; Vomiting 
in, 277 ; Constipation in, 277 ; State of the Ap- 
petite in. 278 : of the Pulse in. 279 ; respiratory 
Disturbances in, 280 ; Condition of the Skin 
in, 281) ; meningitic Spots in, 281 ; Headache 
in. 281 ; abdominal Pains in. 262 ; Shape of the 
Abdomen in, 2^2 ; psychical Disturbances in, 
284 ; hydrocephalic Cry in, 283 ; general and 
local Convulsions in, 284; State of the Pupils 
in, 285; Brachet's Observations on, 285; of 
the Hearing in, 286 ; Termination and Progno- 
sis of, 287 ; Treatment of, 2;8. 

Hydrocephalus, chronic, 297 ; Pathology of, 297; 
acquired, 298; Causes of, 298; Symptoms of, 
299 ; functional Disturbances in, 300 ; Course 
of, .391 ; Treatment of, 392. 

Hydrophlogosis Ventriculorum Cerebri, 296. 

Hydropericardium, 208 ; Pathology of; 208 ; 
Symrtoms of. 209 ; Treatment ot, 209. 

Hydrorrhachia, 312. 

Hydrothorax, 269 ; Causes of. 270 ; Symptoms of, 
270; Prognosis of. 270; Treatment of, 271. 

Hypertrophy Tonsillarum, 115; Treatment of, 
116 
" and Prolapse of the Tongue, 88. 

Hypospadia, 393. 



I. 



Icterus Neonatorum, 75; Treatment of, 75. 

Idiopathic Convulsions, 318. 

Idiotism, 353 ; Symptoms of, 3.53. 

Imbecility, 3.53; "Symptoms of^ 353; Prognosis 

of. 354: Treatment of. 355. 
Impetigo, Eruption of, in difficult Dentition, 108. 

" scrofulous, 577 ; 'iVeatment of, 577. 
Incontinentia Urin», 3.^5, 
Induratio Telae Cellulosae, 70. 
Infarctus Renalis, .5, 372. 
Inflammation of Oilsophagus, 118; Symptoms of, 

US; Treatment, 119. 
i Inflammation of Mucous Membrane of Mouth, 

91 ; Treatment, 93. 
Influenza. 2:'9 

Inguinal Hernia. 163; Treatment, 165. 
Innervation, Influence of, on the Iklilk, 37. 



INDEX. 



633 



Intermittent Fever, 530 ; Etiology of, 530; Symp- 
toms of, 531; Pathology of, 532; Treatment 
of, 533. 
Insolatio, 294. 
Inspection, 19. 

Intestinal Catarrh, 146 ; Causes of, 147 : Symp- 
toms of, 148 ; Treatment of, 
150. 
" " in diflSctilt Dentition. 109. 

" " as a Complication of Diphthe- 

ria, 443. 
" " as a Complication of Small-pox, 

432. 
" " as a Sequel of Measles, 423. 

" Hsemorrhage, 73. 

" "in Typhus Fever, 486. 

" Evacuations " " " 485. 

" Navel, 66. 

" mucous Membrane, Disturbances of, 

in Cholera, 507. 
Intertrigo, 535 ; Treatment of, 535. 
Introductory Remarks, 1. 

Intussusception, 160; Pathology of, 160; Symp- 
toms of, 162; Treatment of, 162; Pfeufer's, 
163. 
Invagination, 160 ; Treatment, 162. 
Involuntary Movements of the Musclei, 329. 
Iodide of Potassium, to detect, in Milk, 39. 
Irideremia, 357. 
Iridoschisma, 356. 

Irritatio Cerebri, 295 ; Treatment, 297. 
Ischuria, 388 ; Treatment of, 389. 
Itch, 537 ; Treatment, 539. 



J. 

Jaundice, 75. 

Joints, Inflammation of the, as a Sequel of Small- 
pox, 432. 
" scrofulous Inflammation of the, 602 ; 
Symptoms of, 604 ; Recovery in, ^vith 
good Use of the, 605 ; vrith impaired 
Function of, 606 ; with Dislocation, 
606 ; Treatment of, 606 ; Jobert's, 607 ; 
Rust's, 607 ; Priesnitz"s Method of, 607. 



K. 



Keratitis Scrofulosa, 581 . 

Kidneys, Malformations of the, 372, simple, 372 ; 
single, 372. 
" Aflfeotions ofthe, 374. 
" Morbid Alterations of, in Cholera Asi- 
atica, 508. 
Knee-joint, scrofulous Inflammation ofthe, 614; 
Symptoms of, 614 ; false Anchylosis in, 615 ; 
true Anchylosis in, 615; Treatment of, 615. 
Kopps's Observations on Thymus Gland, 227. 
Kyphosis Paralytica, 598. 
" Scoliatica, 599. 



Labium Leporinima, 84. 

Lanugo, 6. 

Laryn.\-, Abscesses of the, in Typhus Fever, 488. 

" Neurosisof the, 222. 
Laryngea Tracheitis E.\udativa, 453. 
Laryngitis Catarrhalis, 219. 

" et Tracheitis Maligna, 458. 
" as a Complication of Small-pox, 432. 
Laryngismus Stridiilii.s, 222. 
Laryngo-spasmus Infantilis, 222. 
Leucorrhcea, 404 ; Causes of, 404 ; Treatment of, 

405. 
Lichen, Eruption of, In difficult Dentition, 108. 
Syphilitica, 621. 



Liebig's Soup, 46. 

Lime-Water, Addition of, to Milk, 49. 

Lithiasis, 3S9 ; Symptoms of, 390 ; Course of, 391 ; 

Treatment of, .391. 
Liver, average Weight of the, 181; French's 
Estimate, 181; Portal and Meckel's, 
181. 
" congenital Anomalies of the, 186. 
" " Transpositions of the, 186. 

'• fatty, 183 ; Pathology of, 184 ; Symptoms 

and Treatment of, 185. 
" syphilitic Inflammation ofthe, 182 ; Pathol- 
ogy of, 182 ; Symptoms and Treatment 
of, 182. 
Lobar Pneumonia, 241. 

" in Typhus Fever, 488. 

Lobular Pneumonia, 241. 

Lungs, acquired Atelectasis of, 250 ; pathological 
Anatomy, 250 ; Symptoms of, 350 ; Treat- 
ment, 250. 
" Carcinoma of the, 572 ; Symptoms of, 573 ; 

Treatment of, 574. 
" Gangrene of the, 259 ; Pathology of, 259 ; 
diffused, 259 ; circumscribed, 2G0; Symp- 
toms of, 260 ; Treatment of, 261. 
" Inflammation of the, 241 . 
" Tuberculosis of the, 565; Pathology of, 
565; Symptoms of, 569; Respiration, 
Condition of, in, 570; Expectoration in, 
571. 
Lupus, 578; L. Exfoliatus, 578; L. Exulcerans, 
578; L Serpiginosus, 578 ; L. Tuberusus, 578 ; 
Treatment of, 578. 
Luxatio Spontanea, 608. 

Lymphatic Glands, scrofulous Affections of the, 
585; Pathology of, 585; simple Hypertrophy 
of the, 585 ; Tuberculosis of, 585 ; Treatment 
of, 587. 



M. 



Malformation of Anus and Rectum, 169. 
" Bladder, 380. 
" " Kidneys, 372. 

Male Genitals, Malformations of the, 392. 

Malum Potii, 598. 

Mastitis Neonatorum, 83 ; Treatment of, 84. 

Masturbatio, 396. 

Measles, 418; normal, 419; the Stage of Pro- 
dromata in, 419 ; of Eruption, 419 ; of Flores- 
cence, 420 ; of Desquamation, 420 ; Variations 
of, 421 ; Modification ofthe Exanthema in, 421 ; 
Participation of the mucous Membrane in, 
421 ; Conjunctivitis in, 421 ; nasal Catarrh in, 
422 ; Inflammation of the Glottis in, 422 ; Diph- 
theritis and Coryza in, 422 ; lobar and lobular 
Pneumonia in, 422 ; intestinal Catarrh in. 422 ; 
Character of the Fever in, 422 ; erethitic Form 
of, 422; synochal Form of, 422; torpid Form 
of, 423 ; septic or putrid Form of, 423 ; Seque- 
lae of, 423; Tuberculosis, 423; Otorrhcea, 423; 
Diphtheria, 423 ; intestinal Catarrh, 423 ; Noma, 
423 ; Diagnosis of, 424 ; differential Diagnosis 
of Measles and Scarlet Fever, 425 ; Prognosis 
of, 425; Etiology of, 426 ; Treatment of regu- 
lar, 426 ; of irregular, 427. 

Meatus Auditorius, Abscesses in the, 363. 

" Closure of the, 359 ; Treat- 

ment of. 360. 
" " simple Infl.ammation of the, 

360 ; Treatment, 362. 
" Urinarins, Closure of the, 393. 

Meconium, 4 ; Foerster's Analysis of the, 4. 

Mediastinum Anticum, Carcinoma of. Symptoms 
of, 1572 ; Treatment of, 573. 

Medicines, Effects of, on the Milk, 39. 

Mehlmund, 99, 

MelHina Neonatorum, 73 ; Treatment of, 74 ; 
Killiet's, 74. 

Melansemia, 532. 

Membranous Navel, 06. 



634 



INDEX. 



Membranous Quinsy, 453. 
Meningeal Tuberculosis, 271. 
Meningitis Simplex, 291 ; Etiology of, 291 ; Pa- 
thology of, 291 ; Symptom* of, 292 ; Treatment 
of, 294. 
Meningitis Purulenta, 291. 

" as a Complication of Small-pox, 432. 

Meningitic Spots in acute Hydrocephalus, 280. 
Menstruating Wet-nurses, Banger from, 41. 
Mesenteric Glands, morbid Alterations of, 192. 
Metastases in Scarlet Fever, 41.5. 

" " Typhus Fever, 492. 

Metastatic Parotitis, 529. 
Microstoma, 87 ; Treatment of, 87. 
Microcephalia, 307. 
Mictio Involuntaria, 3S.5. 
Middle Ear, Infl.ammation of the, 364. 
Miliaries in Typhus Fever, 490. 
Milk, Analysis of, 37. 

" Blood-Corpuscles In, 34. 

" Butter in, 35. 

" Casein in, 36. 

" coagulable Fibrin in, 35. 

" Corps Granuleux, 34. 

" Condensed, 48. 

" Cow's, 45. 

" Cream, Addition of, to, 49. 

" Epithelium-Cells in, 36. 

" insoluble Salts in, 35. 

" Lime-Water, Addition of, 49. 

" mucous Corpuscles in, 35. 

" microscopic Examination of the, 34. 

" soluble Salts in, 34. 

" specific Gravity of, 33. 

" Sugar of Milk in, 30. 

'■ Woman's, 32. 

" Test, Henle's, 34. 

" *' Mitscherlich's, 84. 

" " ordinary, 40. 
Mind, Diseases of, 353. 
Mitscherlich's Milk Test, 34. 
Modified Scarlet Fevor, 412. 

" Small-pox, 4;39. 
Moist Girdle, Use of the, in Pneumonia, 249. 
Monophthalmia, 356. 
Morbilli, 418. 

Morbus Brightii, 374 ; Pathology, 374 ; Symptoms, 
375; Treatment, 378. 

" Cerebralis Whyttii, 271. 

" Coxarum, 608. 

" Sacer, 341. 

" Strangulatorius, 453. 
Mortiflcatio i'ulmonum, 259. 
Most important Symptoms of gastric and in- 
testinal Catarrh. 120. 
Mothers' Marks, 539. 
Mouth, Constriction of the. 87. 
" Diphtheria of the, 446. 

" Examination of the, 26. 

" mucous Membrane of the, catarrhalic In- 
flammation of, 91. 
Movements of New-born, 16. 
Mucous corpuscles in Milk, 85. 

" Membranes, scrofulous AfiFections of the, 
.579. 
Mucous Membranes, syphilitic Affections of the, 

623. 
Muguet, 99. 
Miiller, Canals of; 402. 
Mumps, 513. 
Mundsohr, 99. 

Muscles and Bones, syphilitic Affections of, 624. 
Muscular Jactitation, 329. 
Myocarditis as a Complication of Diphtheria, 448. 



N. 



Naevus, congenital, 539. 

" Lipomatodes, 540 ; Treatment of, 540. 
" Vasculosus, 210. 



Nasal Cavities, Exploration of the, 213; Win- 
trich's Method, 213. 
" Mucous Membrane, syphilitic Affections of 

the, 623. 
" Polypi, 217. 
Navel, Blennorrhoea and Ulceration of the, 63; 
Treatment of, 63. 
" Care of the, 52, 64. 
" Diseases of the, 62. 
" Gangrene of the, 63 ; Treatment of, 63. 
" Hsemorrhage of the, 64 ; Treatment ofi 66. 
" Intestinal, 66. 
" Membranous, 66. 
" Rupture of the, 65. 
" Vascular, 66. 
Necrosis, scrofulous, 596 ; Symptoms of. 596 ; 
Prognosis of, 596; Treatment of, 596. 
" as a Sequel of Small-pox, 432. 

Nephritis, 374. 

" as a Complication of Diphtheria, 446. 
Nervous Functions, Distuibance of, 315. 
Nestle's Food, 49. 
Neurosis of Larynx, 222. 
Nocturnal Cough, periodic, 261 ; Treatment of, 261. 

" Micturition in Bed, 385. 
Noma, 97 ; Symptoms of, 98 ; Treatment of, 99. 

" as a Sequel of Measles, 423. 
Nose, adventitious Growths in the, 217. 
" Bleedingof the, 213. 
" foreign Bodies in the, 213 ; Treatment of, 

219. 
" scrofulous Affection of the, 580. 
Normal Navel, Treatment of the, 62. 
Nursing and Care of Children, 29. 
Nursery-room, Condition of, 53. 
Nutrition, artificial, 44. 
Nystagmus Oscillatorius and Eotatorius, 357. 



0. 



Obliteratio Meatus Auditorius, 359. 
Obstipation, 134; Causes, 134; Treatment, 135. 
Obstructio Alvi, 134. 
Occlusion of Anus, 169. 
QJdema Com pactum, 70. 
" Neonatorum, 70. 

" Pulmonum, 2.55 ; Pathology of, 255 ; 
Symptoms of, 256 ; Treatment of, 367. 
" of the Lunsrs in Typhus Fever, 488. 
CEsophagitis, 118; Symptoms of, 118; Treatment 

of, 119. 
Oleuarthrocace, 617 ; Treatment of, 617. 
Omphalocele Congenita, 65. 
Onanism. 396 ; Kraft's case of, 897 ; Causes of, 

398 ; Treatment of, 898. 
Onychia, syphilitic, 624. 
Ordinary Milk Test, 40. 
Organ of Hearing, Malformation of, .358. 
Organs, internal, syphilitic Affection of, 624. 
Organs of Sense, scrofulous Affections of the, 579. 
" " Disturbances of, in acute Hydro- 

cephalus, 282. 
Osteomyelitis, 589 ; Pathology of, 590 ; Treatment 

of, 591. 
Ostitis, scrofulous, 591 ; Osteoporosis, 591 ; Eeso- 
lution in, 592; Suppuration in, 592; Caries as 
a Result of, 593 ; Necrosis as a Result of, 593 ; 
Treatment of, 593. 
Otitis Externa,360 ; catarrhal, 361 ; erythematous, 
360; Symptoms of, 360; Eti- 
ology of, 362; Treatment of. 
362. 
" " Phlegmonosa, 862; Treatment 

of, 364. 
" Interna, 364 ; Diagnosis of, 365 ; Termina- 
tion of, 365; Treatment of, 365; 
the real, 366; Symptoms of, 
366 ; Causes of, 368 ; Treatment 
of, 368. 
Otorrhcea, as a Complication of Small-pox, 432. 



INDEX. 



635 



Otorrhcea as a Sequel of Measles, 423. 
Oxyuris Vermlcularis, 176. 
Ozsena, simple, 530; scrofulous, 580; Treatment 
of, 580. 



P. 



Palatum Fissum, 84. 

Palpation, 24. 

Paraphimosis, acquired, 395 ; Treatment of, 396. 

" congenital, 393. 

Paralysis, 828 ; essential, 323 ; facial, 323 ; Symp- 
toms of, 3-24; Causes of, 326; Treat- 
ment of, 328. 
" as a Complication of Diphtheria, 448. 
" Glottidis, 230; Symptoms of, 230; 
Duration of, 231 ; Treatment of, 231. 
Parotid, Hypertrophy of the, benign, 112 ; Treat- 
ment of, 112. 
Parotid, Hypertrophy of the, malignant, 112; 

Treatment of, 112. 
Parotitis, idiopathic. 111; Syinptoms of, 112; 
Course and Termination of, 52T ; 
Contagiosa, Pathology of, 526; Ther- 
apeutics of 528. 
« metastatic, 529 ; Treatment of, 530. 

" secondary, 528 ; Treatment of, 529. 

" as a Complication of Typhus Fever, 

488. 
Pathology of Diphtheria and Croup, 463. 
Pelvis, Rachitis of the, 564. 
Pemphigus Benignus, contagiosa, 444 ; Treatment, 

445. 
Pemphigus Syphilitica, 621. 
Penis, Malformation of the, 392. 
Percussion, 20. 
Pericarditis, 199 ; Pathology of, 201 ; Symptoms 

of, 202 ; Treatment of, 2U8. 
Pericardium, Dropsy of the, 208; Pathology of, 

208; Symptoms of, 209; Treatment of, 209. 
Periodic nocturnal Cough, 261 ; Treatment of, 261. 
Periostitis of the middle Ear, 366. 

" scrofulous, 587; Pathology of, 588; 
Hypertrophy as a Result of, 588 ; 
Resolution In, 588 ; Suppuration in, 
588; Prognosis of, 5S9; Treatment 
of, 589. 
Peritonitis, acute, 18S ; Causes of, 188; Symptoms 
of, 183; Pathology of, 188; Treat- 
ment of. 189. 
" chronic, 187. 

Pertussis, 513. 

Perforating Ulcer of the Stomach, 140. 
Perspiration in Typhus Fever, 489. 
Petechia in Typhus Fever, 489. 
Petechial Fever, 497. 

Pharyngo-laryngitis Pseudomembranacea, 453. 
Phimosis, congenital, 392; Treatment of, 392. 
Phlebitis and Arteritis Umbilicalis, 62 ; Treat- 
ment of, 6'^. 
Phreno-glottismus, 222. 
Physiological Dentition, Irregularities of, 13. 
Pigmentary Naivi, 5.39. 
Pityriasis Linguae, 105. 

Pleurisy, 262; Pathology of, 263; Complications 
of, 263; Symptoms of, 264; Treat- 
ment of, 263. 
" dyscrasiac, 267. 
" purely inflammatory, 269. 
" as a Complication of Small-po.x, 432. 
Pleuritis, 2(i2. 
Pneumonia, 241 ; Pathology of, 242. 

" lobar, 242; Infiltration, purulent, in, 

242. 
" lobular, 242; Symptoms of, 242; 

Percussion in, 24."); Auscultation 
in, 24.5; Palpation in, 24.'>; Course 
of, 24(i ; Treatment of, 247. 
" as a (Complication of Diphtheria, 418. 

Podarthrocace, 616. 



Polyphagia, 123. 

Polypi, nasal, 217 ; Etiology of, 218 ; Symptoms 
of, 218 ; Treatment of, 218. 
" rectal, 166; Treatment of, 167. 

Pomphi, 107. 

Porrigo, 576. 

" Eruption of, in difficult Dentition, 108. 

Position of Extremities at first Dressing, 52. 

Practical Examination of Milk, 40. 

Pregnancies, Recurrence of, in Lactation, 40. 

Prepuce, Inflammation of the, 394. 

Prolapsus Ani, 167; Causes of, 168; Prognosis o^ 
168; Treatment of, 163. 
" Linguae, 88 ; Treatment of, 89. 

Prurigo, 108. 

Pseudo-croup, 21 9 ; Svmptoms of, 220 ; Dura- 
tion of, 220 ; Treatment of, 221. 

Psychical Disturbances in acute Hydrocephalus, 
282. 

Pulmonary Emphysema, 353. 

Pulse, Examination of the, 17. 

" State of the, in acute Hydrocephalus, 286. 

Pupils, State of the, in acute Hydrocephalus, 286. 

Putrid sore Mouth, 93 ; Treatment, 95. 

Pysemia as a Complication of SmaU-pox, 432. 



Quaddeln, 107. 



Q. 



R. 



Rachitis, 544 ; Pathology of, 544 ; Symptoms of, 
549. 
" of the Extremities, 554 ; of the Pelvis, 
554 ; of the Thorax, 552 ; Relation 
of to Scrofula and Tuberculosis, 556 ; 
Prognosis of, 557 ; Etiology of, 556 ; 
Treatment of, 557. 
" of the Skull, 549. 

Ranula, 89 ; Prognosis of, 90 ; Treatment of, 91. 
Rectum, Malformation of the, 169 ; Treatment of, 

171. 
Rectum, Polypi of, 166; Treatment of, 167. 
Renal Calculi, 379. 
" Tubercle, 879. 
" Cysts, 380. 
Relapses in Typhus Fever, 484. 
Relation of Rachitis to Scrofula and Tuberculosis, 

556. 
Remedies, the Influence of Milk, 39. 
Ren Unguiformis, 372. 
" Reprise " in Whooping-cough, 514. 
Respiration and Circulation. 1. 

" Disturbance of the, in Cholera, 508. 

" Disturbance of the, in acute Hydro- 

cephalus, 279. 
" Condition of the, in pulmonary Tu- 

berculosis, 560. 
Respiratory Organs, Examination of, 19. 
Retention of Urine, 388. 
Retropharyngeal Abscesses, 116; Prognosis of, 

116: Treatment of, 117. 
Rhagades, syphilitic, 622. 
Rheumatism, acute, 200; Symptoms of, 200; 

Treatment of, 208. 
Rhinitis, 215. 
Rickets, 544. 
Roseola Syphilitica, 620. 

" Typhosa, 489. 
Rotheln, 428. 
Round Worm, 175. 
Rubeola, 428 ; Symptoms of, 428 ; Treatment of, 

429. 
Rules for Examination of Children, 14 
Rupia, scrofulous, 577 ; Treatment of, 577. 
Rupture of the umbilical King, 65. 
" " " Cord, 65. 



636 



INDEX. 



S, 

Salts, insoluble in Milk, 3T. 
soluble " " 37. 
Scabies, 53T; Treatment of, 539. 
scarlatina, 4U8 ; s. Exanthemata, 408. 
" Legitlmata, 408. 
" Levigata, 412. 
" Papulosa, 412. 
" Variegata, 412. 
Scarlet Fever, normal, 40S ; Stage of Eruption 
and Florescence, 409; of Des- 
quamation. 410; of Incuba- 
tion and Premonition, 40s. 
" Participation of the mucous Mem- 

brane in. 412. 
" anomalous Localizations of, 414. 

" Intensity of the general System 

in. 413. 
" Modification of Form of the Ex- 

anthema in, 412. 
" Metastases in. 41.5. 

» Sequels of. 415 ; Etiology of. 415 ; 

Treatment of 410; Schnee- 
mann's Method of, 417. 
Schnuller, 50. 
Scleroma, 70 ; SjTuptoms of, 71 ; Pathology of, 

72 ; Causes of, 72 ; Treatment of, 73. 
Sclerosis of the Brain, 304. 
Scrotum, Gangrene of the, as a Complication of 

Small-pox, 432. 
Scelotyrbe, 329. 

Sclerosis of Sterrio-cleido-mastoideus Muscle, 120. 
Scoliosis, 594. 

Scorbutus, 96 ; Symptoms of, 96 ; Treatment of 97. 
Scrofula, 559; Connection of, with Tuberculosis, 

559. 
Scrofulous Cachexia, 574 ; general Treatment of, 

618. 
Seborrhoea Capillitii, 6. 
Secretions, 4. 
Sehnenflecke, 205. 
Serous Effusions, 25. 

Sexual Functions. Influence of, on the Milk, 41. 
Simple (Edema, 877. 

Skin, Condition of the, in acute Hydrocephalus, 
280. 
" " in the New-born, 6. 

" " of the. in Typhus Fever, 489, 

" Color of the, in Tuberculosis, 562. 
" the Culture of, .52. 
" scrofulous Affections of the, 576. 
" Syphilitic Affections of 620. 
Skull, Measurements of the, 7. 

" fiachitis of the, 549. 
Small-pox, 430. 

" " modified, 4.39. 
Smegma Cutaneum, 5. 
Soor, 99. 

Soda Bicarb., Use of, in Milk, 45. 
Spasms, 31.5. 

Spasmus Glottidis, 222 ; Symptoms of 223 ; gen- 
eral Convulsions in, 222 "; Duration, Course, and 
Prognosis of 224 ; Causes of 225 ; general, 
274; Influence of Age on, 226 ; hereditary 
Character of 226; Connection between ("ranio- 
tabes and, 226 ; Pathologv of 227 ; Treatment 
of 223 ; prophylactic. 22-<; of the Attack, 228; 
of the Cause, 229 ; Scarification of the Gums 
in. 229. 
Spilus, .539. 

Spina Bifida, 312 : Pathologv of 312 : Symptoms 
of, 313 ; Treatment of, 314 ; 
Chassaignac's, 314. 
" Ventosa, .590. 
Spinal Meningitis and Mvelitis. 808 ; Pathologv 
of 309 ; Symptoms of, 310 ; Treatment of, 
312. 
Spleen, Enlargement of, in Typhus Fever, 483. 

" Hj-pertrophy of, 187. 
Spondylarthrocace, 598. 



Spondylarthrocace Cervicalis, 600. 
" Lumbalis. 601. 

" Thoracica, 600. 

" Treatment of, t02. 

Spring- worm, 176. 
Spotted Fever, 497. 

Sprue. 99 ; Symptoms of, 99 ; Treatment of, 104. 
St. Vitus's Dance, 329 ; Treatment of, 3.U. 
Sterno-cleido-mastoideus Muscles, Sclerosis of 

the, 120 ; Treatment of, 120. 
Stigmata, 539. 

Stomacace, 93; Causes of, 94; Treatment of, 95. 
Stomach, catarrhalic Inflammatiofi of the, 186; 
Symptoms of, 136; Treatment of, 
137. 
" perforating Ulcer of the, 140. 

" Softening of the, 141. 

" " black, 143. 
" " " " gelatiniform, 143. 

" to.Tic Inflammation of the, 1-37 ; Symp- 

toms and Pathology of, 138; Treat- 
ment of, 139. 
Stomatitis Catarrhalis, 91 ; Ulcerosa, 92 ; Treat- 
ment of 93. 
" Cremosa, 99. 

Stomato Necrosis, 97. 
Stone-pox, 441. 
Strophulus Syphilitica. 621. 
Struma, 231. 

Cystica, 232. 
" Lymphatica. 282. 
" Treatment ot. 232. 
Subcutaneous Cellular Tissue, syphilitic Affection 

of the, 623. 
Sucking-bottles, 50. 
Suctus Voluptibilis. 351. 
Sudamina Rubra, 555. 
Sugar-teat, 50. 

" of Milk in Milk, 35. 
Suffocatio Stridula, 453. 
Sunstroke, 294 ; Symptoms of, 294 ; Treatment 

of, 295. 
Swine-po.x, 539. 
Syncope of the New-born, 54. 
" in Tracheotomy, 468. 
Syphilis, hereditary, 6-M; Course and Termina- 
tion, 625; Etiology of, 625 ; Treatment of, 626. 
Syphilitic Affections of mucous Membrane, 623. 
" Skin, 620. 
" Cellular Tissue, 623. 

" " Bones, 624. 

" " Glandular Organ.=;. 624. 

" " Internal Organs, 624. 



Tabes Mesenterica, 153; Pathology of, 158; 
Symptoms of, 154 ; Treatment of, 156. 

Taches Lenticularis, 489. 
" Meningitique, 2sl. 

Tieniee Solium, 173. 

Teeth, Eruption of the, 11. 

Teleangiectasis, arterial, 210. 

Testes, concealed, 398. 

Tetanus Apnoecus, 222. 

" Neonatorum, 67 ; Symptoms of, 69 ; 
Causes of 68 ; Prognosis of, 69 ; Treat- 
ment of 69. 

The Articles of Food of Wet-nurse, Influence of, 
38. 

The Cough, 27. 

The Cry, 26. 

The sexual Function, Influence of on Milk, 39. 

The Time that has elapsed since Confinement, In- 
fluence of. on Milk, 38. 

Thermoraetric Measurements, 18. 

Thighs, Examination of the inner Surfaces of the, 
26. 

Thorax. Rachitis of the, 5.52. 

Thrombi in the Sinuses of the Dura Mater, 212. 



INDEX. 



637 



Thrush, 99 ; Symptoms of, 100 ; Causes of, 104 ; 

Treatment of, 104. 
Thymiae, the Odor of the, in Milk, 39. 
Thymus Gland of New-born, 3. 
Thymus Gland, 233 ; Carcinoma of the, 233; Tu- 
berculosis of the, 233 ; syphilitic Abscesses of 
the, 624 ; syphilitic Cysts of the, 624. 
Thyroid Gland, 231. 
Tinea Capitis, 5T6. 

Tongue, abnormal Adhesions of the, 89. 
" Examination of the, 26. 
" Hypertrophy and Prolapse of the, 8S ; 

Treatment of, t8. 
" Imperfect Development of the, 88. 
Tonsillitis, 113. 
Tonsils, Hypertrophy of the, 115 ; Treatment ot 

116. 
Toxic Inflammation of the Stomach, 136. 
Tracheotomy, 467 ; Method of performing, 468 ; 

Haemorrhage from, 46S ; Syncope in, 463. 
Tremors of the Head, 325. 
Tricocephalus Dispar, 172. 
Trimesters, 9. 

Trismus of the New-born, 67. 
Tubercles, aggregated, 567. 
" Cerebral, 305. 

" Infiltration, 565. 

Tuberculosis of the bronchial Glands, 565 ; of the 
Lungs, 565 ; Pathology of, 565 ; 
Symptoms of, 569 ; State of the 
Kespiration in, 570; Cough in, 
570; Expectoration in, 571 ; 
Course of, 572. 
" of the Brain, 305. 

" Connection of, with Scrofula, 559. 

" of the Kidney, 379. 

" " Mesenteric Glands, 192. 

" " Vi^rtebraj, 598. 

" as a Sequel of Measles, 423. 

" transmissibility of, by the Milk, 44. 

Tuberculous Cachexia, 560 ; general Symptoms 
of, 560 ; Color of the Pace in, 560 ; hectic Fever 
in, 561 ; Condition of the Skin in, 562; gen- 
eral CEdema in, 562 ; Prognosis of, 562 ; Etiol- 
ogy of, 563 ; general Treatment of, 618. 
Tumor Albus Articuli Pedis, 616. 

" Genu, 614. 
Tumors, Fatty, 540. 
Tussis, 513. 

" Convulsiva, 513. 
" Suflfocativa. 513. 
Typhus Fever, 477; Pathology of, 478; Symp- 
toms of, 480; Chronology of, 481 ; Metastases 
in, 492 ; Koseola Typhosa, 489 ; Taches Len- 
ticularis, 4S9 ; Treatment of, 493. 



u. 



Ulceration of the Navel, 63 ; Treatment of, 63. 
Ulceratio Ossis. 593. 

Ulcus Ventriculi Ptotundum sive Perforans, 140. 
Umbilical Arteries, 2. 

" Eing, acquired Rupture of the, 65; 

Treatment of, 66. 
" Stump, Ulceration of the, 64; Treat- 
ment of, 64. 



Umbilical Vessels, Inflammation of the, C2 ; 

Treatment of, 63. 
Urethra, anomalous Openings of the, 393. 
Uric-acid Infarction of the New-born, 5, 372. 
Urine. Retention of, 388. 

Urticaria, Eruption of, in difficult Dentition, 107. 
Uterus BicorniSj 403. 

" Unicornis, 403. 



Vaccination, 433. 

" Method of performing, 434. 

Vaginae, Ha;morrhage of, 406. 

Varicellse, 439 ; Symptoms of, 441 ; Treatment of, 
443. 

Variola, 430 ; Symptoms of, 430 ; Stage of Incu- 
bation and Prodromata, 480; of Eruption and 
Florescence, 480 ; of Desiccation, 431 ; Compli- 
cations of, 432; Etiology of, 432; Sequelae of, 
432; Treatment of, 432. 

Varioloid, 4.39; Symptoms of, 439; Sequelae of, 
440 ; Prognosis of, 440 ; Treatment of, 441. 

Vascular Navel, 66. 
" Tumors, 61. 

Vernois and Becquerel's Analysis of Milk, 318. 
" " " " in good 

and In average Nutrition, 87. 

Vernix Caseosa. 5. 

Vertebra, scrofulous Inflammation of the, 598. 

Vesical Calculi, 389; Symptoms of, 890; Course 
of. 391 ; Treatment of, 391. 

Vitus's Dance, St., the great, 338. 
" " " little, 829. 

Voice, Palpation of the, 24. 

Voluptuary Indulgence, 351. 

Vomiting, 124; Treatment of. 126. 

" in acute Hydrocephalus, 27T. 

Volvulus, 160. 

w. ■ 

Warts, 640. 

Wasserkrebs, 97. 

Water-pox, 441. 

Weaning of the Child, 42. 

Wormuth, Taste of, in Milk, 39. 

Wet-nurse, Diet and Hygiene of the, 41. 
" Selection of a, 82. 

Wet-nurses, Donne's Classification of, 80. 

Whip-worm, 176. 

White Swelling of the Knee-joint, 614. 

Whooping-cough, 513; Symptoms of, 513 ; "Re- 
prise" in, 514; Complications of, 517; Diag- 
nosis of, 518: Pathology of, 518; Etiology of, 
519 ; Treatment of, 5:!0. 

Wintrich's Method of exploring the nasal Cavi- 
ties, 21.3. 

Worm-disease, 172 ; Symptoms of, 177 ; local, 
177 ; general and reflex, 178 ; Treatment o£ 
179. 



Zellgewebsverhiirtung, 70. 
Ziegenpeter, 526. 
Zulp, 50. 



EXPLANATION TO PLATES. 



PLATE I. 



. Placenta. II. Liver. III. Heart. IV. Kidneys. V. Bladder. 
(1.) Arcli of the Aorta and vessels of tlie neck arising from it. 
(2.) Ductus arteriosus Botalli. 
(3.) Arteria pulmonalis. 
(4.) Ductus venosus Arantii. 
(5.) Vena cava superior. 
(6.) Vena cava adscendens. 
(V.) Vense pulmonales. 
(8.) Vena umbilicalis. 
(9.) Arterise umbilicales. 

PLATE II. 

Figs. 1 and 2. Schematic drawings of the Parietal Bone for the demonstration of the 

physiological enlargement of the greater fontanel. 
Fig. 3. Normal human Milk, according to Funke. 
Fig. 4. Normal Colostrum, according to Funke. 
Figs. 5, 6, and 7. Schematic Sections of various kinds of Cephalsematomse. Fig. 5. 

Cephalajmatoma subpericranicum. Fig. 6. Ceph. subaponeuroticum. Fig. 7. Ceph. 

durse matris. 

(1.) Scalp. (2.) Galea aponeurotica. (3.) Pericranium. (4.) Cranial bone. 
(5.) Dura mater. (6.) Bony-ring (only possible in Fig. 5). 
Fig. 8. Schematic Section of an Umbilical Stump, (a) Stump, (b) the Cutaneous Eing 

surrounding it. 
Fig. 9. a and b Schematic Delineation of the so-called Flesh-navel, (a), previous; 

(6), after the Cord has fallen off. 

PLATE III. 

Fig. 1. Impressions of the Teeth in the Tongue in Stomacace. 

Fig. 2. Thrush-fungi, according to Kuechenmeister. 

(a) Fragment of a detached Thrush-membrane, (6) and (c) Spores, {d) Thallu8 
filaments with sheaths, (e) Free end of a Thallus filament slightly thickened, (g) 
Thallus filaments, with indentations. 

Fig. 3. A, Intussusception of a piece of the Intestines ; B, Schematic Section, accord- 
ing to Foerstcr. (a) the Intussusceptum, (J) the Reflected portion, and (c) the 
Sheath, (d) and (e) the place of reflection, (/) the dragged in Mesentery. 

Fig. 4. Longitudinal Section of the Sacrum and of the Eectum. (1.) Sacrum. (2.) Eec- 
tura. (a) upper, (b) middle, and (c) lower portion of the Eectum. (3.) Peritonoeura, 
(4.) Uterus. (5.) Vagina. (6.) Labia. (7.) Bladder. (8.) Perinteum. 



640 EXPLANATION TO PLATES. 

Figs. 5, 6, 7, 8, and 9. Schematic sections of imperforation of the Kectum and of its 
abDormal terminations : (r), Eectum ; («), Nates-fold ; (a), Anal-invagination ; (6), 
Bladder; (v), Vagina. 
Fig. 10. Schematic delineation of an Ectopia of the Bladder, according to Foerster. 
Figs. 11, 12, 13, and 14. Schematic representation of Hydroceles. 
Fig. 11. Hydrocele canalis vaginalis testiculi aperta. 
" 12. Hydrocele fundi canalis vaginalis tebticuli clausa. 
" 13. Hydrocele colli canalis vaginalis testiculi aperta. 
" 14. Hydrocele colli canalis vaginalis testiculi claicsa. 

(a), Piece of the Peritonaeum viewed from within ; (5), Open canalis va- 
ginalis ; (c), Testicle ; (d), Dropsical distension of a portion of the 
Inguinal Canal. 



PLATE IV. 

Figs. 1-3. Bothriocephalus latus. 

Fig. 1. Head, natural size. 

Fig. 2. Magnified head with long neck. 

Fig. 3. Single pieces. The sexual opening is seen in the centre of each joint. 
Figs. 4-7. Tffinia solium. 

Fig. 4. Head, natural size. 

Figs. 5 and 6. Magnified Head, seen from the side and from above. 

Fig. 7. Joints. The sexual opening is seen at the side. 
Figs. 8-9. Ascaris lumbricoides, Kound-worm. 

Fig. 8. A ruptured female of natural size, with prolapsed intestines. The brown- 
ish-colored pouch is the alimentary canal, the white coils are the ovaries. 

Fig. 9. The curved tail of the male with double prongs, magnified. 
Figs. 10-13. Oxyuris vermicularis, Thread-worm. 

Figs. 10 and 11. Female, natural size and magnifigd. 

Figs. 12 and 13. Male, magnified and of natural size. 
Figs. 14 and 15. Tricocephalus dispar, Whip-worm, natural size. 

Fig. 14. Female. Fig. 15. Male. 

PLATE V. 

Figs. 1 and 2. Schematic section of (1) normal, and (2) rachitic infantile thorax. 

(1.) Sternum. (2.) Costal Cartilages. (3.) Eibs. (4.) Bibs divided by the sec- 
tion. (5.) Intercostal spaces. (6.) Fifth dorsal vertabra. (7.) Heart. (8.) 
Bulbous, rachitic hypertrophy. 



PLATE VL 

Fig. 1. Eachitic costal ends, according to Virchow. 

Fig. 2. Sections of the same. 

Fig. 3. Section of a rachitic femur. 

Figs. 1, 2, 3. (a), bluish layer of large cancellous bony extuberance ; (J), Goblet-shaped 
tumefaction of the young bones ; (c), Dentated wave-line between the cartilage 
and bone. 

Fig. 4. Eachitic Skull. Craniotabes, according to Elsaesser, On the light-colored 
places the calcareous salts have disappeared, dura mater and pericranium are in con- 
tact with each other. 



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of Midwifery and the Diseases of Women in the Bellevue Hospital Medical 
College ; late Obstetric Physician to Bellevue Hospital ; Surgeon to the 
New York State Woman's Hospital, etc. 

Fourth edition, i vol., 8vo, 526 pp. Cloth, $5.00; sheep, $6.00. 

" For nearly twenty years it has been my duty, as well as my privilege, to give clinical lectures 
at Bellevue Hospital, on midwifery, the puerperal, and the other diseases of women. This volume 
is made up substantially from phonographic reports of the lectures which I have given on the 
puerperal diseases. Having had rather exceptional opportunities for the study of these diseases, 
I have felt it to be an imperative duty to utilize, so far as lay in my power, the advantages which 
1 have enjoyed for the promotion of science, and, I hope, for the interests ot humanity." — From 
Author's Preface. 

ON SEA-SICKNESS. By Fordyce Barker, M. D. 

I vol., i6mo, 36 pp. Flexible cloth, 75 cents. 

Reprinted from the " New York Medical Journal." By reason of the great demand for the 
number of that Journal containing the paper, it is now presented in book form, with such prescrip- 
tions added as the author has found useful in relieving the suffering from sea-sickness. 

PARALYSIS FROM BRAIN DISEASE IN ITS COM- 
MON FORMS. By H. Charlton Bastian, M. A., M. D., Fellow of the 
Royal College of Physicians ; Professor of Pathological Anatomy in Uni- 
versity College, London. 

With Illustrations, i vol., i2mo, 340 pp. Cloth, $1.75. 

" These lectures were delivered in University College Hospital last year, at a time when I was 
doing duty for one of the senior physicians, and during the same year — after they had been repro- 
duced from very full notes taken by my friend Mr. Jolin Tweedy — they appeared in the pages of 
' The Lancet.' They are now republished at the request of many friends, though only after having 
undergone a very careful revision, during which a considerable quantity of new matter has been 
added. It would have been easy to have very much increased the size of the book by tlie intro- 
duction of a larger number of illustrative cases, and by treatment of many of the subjects at greater 
length, but this the author has purposely abstained from doing under the belief ihat in its present 
form it is likely to prove more acceptable to students, and also perhaps more useful to busy prac- 
titioners." — Extract from Preface. 

THE MANAGEMENT OF INFANCY, Physiological and 

Moral. Intended chiefly for the Use of Parents. P.y Andrew Combe, M. D. 
Revised and edited by Sir James Clark, K. C..B., M. U., F. R. S., Physician- 
in-ordinary to the Queen. 

First American from the tenth London edition. I vol., i2mo, 302 pp. Cloth, $1.50. 
" This excellent little book should be in the hand of every mother of a family." — The Lancet. 



D. APPLETON &- CO:S MEDICAL WORKS. 



ADOLPH STRECKER'S SHORT TEXT-BOOK OF OR- 
GANIC CHEMISTRY. By Dr. Johannes Wislicenus. Translated and 
edited, with Extensive Additions, by W. H. Hodgkinson, Ph. D., and A. J. 
Greenaway, F, I. C. 

8vo, 789 pp. Cloth, $5.00. 

The great popularity which Professor Wislicenus's edition of " Strecker's Text-Book of Or- 
ganic Chemistry " has enjoyed in Germany has led to the belief that an English translation will 
be acceptable. Since the publication of the book in Germany, the knowledge of organic chem- 
istry has increased, and this has necessitated many additions and alterations on the part of the 
translators. 

Specimen of Illustration. 



" Let no one suppose 
that in this ' short text- 
book ' we have to deal with 
a primer. Ever\-thing is 
comparative, and the term 
' short ' here has relation 
to the enormous develop- 
ment and extent of recent 
organic chemistry. This 
solid and comprehensive 
volume is intended to rep- 
resent the present condi- 
tion of the science in its 
main facts and leading 
principles, as demanded 
by the systematic chemical 
student. We have here, 
probably, the best extant 
text-book of organic chem- 
istry. Not only is it full 
and comprehensive and 
remarkably clear and me- 
thodical, but it is up to the 
very latest moment, and it 
has been, moreover, pre- 
pared in a way to secure 
the greatest excellences 
in such a treatise." — T/ie 
Popular Science MoritJily. 



PRINCIPLES OF MENTAL PHYSIOLOGY, with their 

Applications to the Training and Discipline of the Mind and the Study of 
its Morbid Conditions. By William B. Carpenter, M. D., LL. D., Reg- 
istrar of the University of London, etc. 

I vol., 8vo, 737 pp. Cloth, $3.00. 




"Among the numerous eminent writers this 
country has produced, none are more deserving of 
praise for having attempted to apply the results of 



physiolog^ical research to the explanation of the mu- 
tual relations of the mind and body than Dr. Car- 
penter." — The Lancet. 



HEALTH. By W. H. Corfield, Professor of Hygiene and 
Public Health at University College, London. 

I vol., l2mo. Cloth, $1.25. 



" Few persons are better qualified than Dr. Cor- 
field to write intelligently upon the subject of health, 
and it is not a matter for surprise, therefore, that he 
has given us a volume remarkable for accuracy and 
interest. Commencing with general anatomy, the 
bones and muscles are given attention ; next, the 



circulation of the blood, then respiration, nutrition, 
the liver, and the execretory organs, the nenous 
system, organs of the senses, the health of the indi- 
vidual, air, foods and drinks, drinking-water, cli- 
mate, houses and towns, small-pox, and communi- 
cable diseases." — Philadelphia Item. 



D. APPLETON &- CO:S MEDICAL WORKS. 



THE BRAIN AS AN ORGAN OF MIND. By H. 

Charlton Bastian, M, A., M. D„ Fellow of the Royal College of Phy- 
sicians ; Professor of Pathological Anatomy in University College, London. 
With 184 Illustrations and an Index, i vol., i2mo, 708 pp. Cloth, $2.50. 



" This work is the best book of its kind. It is 
fall, and at the same time concise ; comprehensive, 
but confined to a readable limit ; and, though it 
deals with many subtile subjects, it expounds them 
in a style which is admirable for its clearness and 
simplicity. " — Nature. 

" The fullest scientific exposition yet published 
of the views held on the subject of psychology by 
the advanced pliysiological school. It teems with 
new and suggestive ideas." — Lo)idon Athenceiim. 



' ' Dr. Bastian 's new book is one of great value 
and importance. The knowledge it gives is univer- 
sal in its claims, and of moment to everybody. It 
should be forthwith introduced as a manual into all 
colleges, high schools, and normal schools in the 
country ; not to be made a matter of ordinary me- 
chanical recitations, but that its subject may arrest 
attention and rouse interest, and be lodged in the 
minds of students in connection with observations 
and experiments that will give reality to the knowl- 
edge required." — Popular Science Mottthly, 



TREATISE ON MATERIA MEDICA AND THERA- 

PEUTICS. Revised and enlarged. Edition of 1883, with Complete Index 
and Table of Contents. By Roberts Bartholow, M. A., M. D., LL.D., 
Professor of Materia Medica and Therapeutics in the Jefferson Medical Col- 
lege ; formerly Professor of the Theory and Practice of Medicine, and of 
Clinical Medicine, and Professor of Materia Medica and Therapeutics in 
the Medical College of Ohio, etc. 

Fifth edition, revised and enlarged, i vol., 8vo. Cloth, $5.00 ; sheep or half russia, $6.00. 

"The appearance of the sixth decennial revision of the ' United States Pharmacopoeia' has 
imposed on me the necessity of preparing a new edition of this treatise. I have accordingly adapted 
the work to the official standard, and have also given to the whole of it a careful revision, incorpo- 
rating the inore recent improvements in the science and art of therapeutics. Many additions have 
been made, and parts have been rewritten. These additions and changes have added about one 
hundred pages to the body of the work, and increased space has been secured in some places by 
the omission of the references. In the new material, as in the old, practical utility has been the 
ruling principle, but the scientific aspects of therapeutics have not been subordinated to a utilita- 
rian empiricism. In the new matter, as in the old, careful consideration has been given to the 
physiological action of remedies, which is regarded as the true basis of all real progress in thera- 
peutical science ; but, at the same time, I have not been unmindful of the contributions made by 
properly conducted clinical observations." — From Preface to Fifth Edition. 



" The author has adapted the present edition to 
the changes made in the sixth edition of the ' Unit- 
ed States Pharmacopceia.' He has also given the 
whole work a careful revision, incorporating the 
more recent improvements and additions to thera- 
peutics. About one hundred pages are thus added 
to the volume. The valuable practical character of 
Dr. Bartholow's treatise has been recognized by the 
profession, and probably no one has succeeded bet- 
ter in popularizing the physiological in distinction 
from the empirical mode of studying therapeutics. 
The book is so excellent a one that we can hardly 
pick out any faults without venturing dangerously 
near hypercriticism." — Medical Record. 

" Professor Bartholow has special talent for con- 
densation, combined with a comprehensive knowl- 
edge of his subject, and a power of direct expres- 
sion. That this combination is gratefully apjjre- 
ciated by the overworked American student, and the 
no less overworked pliysician, has been fully demon- 
strated by the remarkable demand for this wf)rk on 
Therapeutics, which has now attained its fifth edi- 
tion in less than seven years. On account of its 
convenience for reference and completeness, it has 
been adopted as a text-book in many of our medi- 
cal colleges." — Pliiladclphia Medical Times. 

"A book which has reached its fifth edition so 



rapidly as this has done, and upon which the pro- 
fession has passed so favorable a judgment, hardly 
stands in need of a review, or of having its merits 
pointed out. It is not out of place, however, to 
note that it has been kept fully abreast of the many 
and important changes constantly making in the 
knowledge of drugs, and their application to dis- 
ease, to say nothing of hydro-, electro-, and metallo- 
therapeutics, all of which are thoroughly treated in 
this edition. . . ." — Aiiierican Journal 0/ tlie Med- 
ical Sciences. 

"We have lately had occasion to notice a num- 
ber of new works, and new editions of well-known 
text-books, on materia medica and therapeutics, and 
on a great proportion of them we have bestowed 
high commendation. To none, however, is greater 
praise to be awarded than to this fifth edition of 
Professor Bartholow's. The appearance of the new 
Pharmacopceia has rendered a number of changes 
in phraseology necessary, but, in addition to those, 
the volume bears evidence throughout of having 
been brought well up to the present state of our 
knowledge. In consonance with the general voice 
of the profession, we must say that practitioners of 
medicine can scarcely afford to forego the advan- 
tages to be derived frf)m the possession of this 
book." — New York Medical jfoia-nal. 



D. APPLE TON C- CO.'S MEDICAL WORKS. 



A TREATISE ON THE PRACTICE OF MEDICINE, 

for the Use of Students and Practitioners, By Roberts Bartholow, 
M. A., M. D., LL. D., Professor of Materia Medica and General Therapeu- 
tics in the Jefferson Medical College of Philadelphia ; recently Professor of 
the Practice of Medicine and of Clinical Medicine in the Medical College 
of Ohio, in Cincinnati, etc., etc. 

Fifth edition, revised and enlarged, i vol., 8vo. Cloth, $5.00; sheep or half russia, $6.00. 

« 
The same qualities and characteristics which have rendered the author's "Treatise on Materia 
Medica and Therapeutics " so acceptable are equally manifest in this. It is clear, condensed, and 
accurate. The whole work is brought up on a level with, and incorporates, the latest acquisitions 
of medical science, and may be depended on to contain the most recent information up to the date 
of publication. 



Specimen of Illustration. 







" Probably the crowning; feature of the work be- 
fore us, and that which will make it a favorite with 
practitioners of medicine, is its admirable teaching 
on the treatment of disease. Dr. Bartholow has no 
sympathy with the modern school of therapeutical 
nihilists, but possesses a wholesome belief in the 
value and efficacy of remedies. He does not fail to 
indicate, however, that the power of remedies is 
limited, that specifics are few indeed, and that rou- 
tine and reckless medication are dang^erous. But 
throughout the entire treatise in connection with 
each malady are laid down well-defined methods 
and true principles of treatment. It may be said 
with justice that this part of the work rests upon 
thoroughly scientific and practical principles of ther- 
apeutics, and is executed in a masterly manner. No 
work on the practice of medicine with which we are 
acquainted will guide the practitioner in all the de- 
tails of treatment so well as the one of which we are 
writing. " — American Practitioner. 

" The work is concise and definite in its state- 
ments, and eminently practical in its teachings. It 
is written with special reference to the needs of the 
student, and will at once take its place as a text- 
book in many medical schools. It will be found of 
equal value to the practicing physician." — Maryland 
Medical Jonrjial. 

" The volume before us gives not only full and 
correct descriptions of diseases, but the treatment is 
enlivened under the instruction of a new therapy, 
which must commend itself to every student. It is 
an honor alike to authors and the profession of the 
country." — Southern Medical Record. 



' ' The work as a whole is peculiar, in 
that it is stamped with the individuality of 
its author. The reader is made to feel that 
the experience upon which this work is 
based is real, that the statements of the 
writer are founded on firm convictions, and 
that throughout the conclusions are emi- 
nently sound. It is not an elaborate trea- 
tise, neither is it a manual, but half-way 
between ; it may be considered a thorough- 
ly useful, trustworthy, and practical guide 
for the general practitioner." — Medical Rec- 
ord. 

" It may be said of so small a book on 
so large a subject, that it can be only a sort 
of compendium or vade mecutn. But this 
ciiticism will not be just. For, while the 
author is master in the art of condensation. 
It will be found that no essential points have 
been omitted. Mention is made at least of 
every unequivocal symptom in the narra- 
tion of the signs of disease, and character- 
istic symptoms are held well up in the fore- 
ground in every case." — Cincinnati Lancet 
aftd Clinic. 
" Dr. Bartholow is known to be a veiy clear and 
explicit writer, and in this work, which we take to 
be his special life-work, we are verj- sure his many 
friends and admirers will not be disappointed. We 
can not say more than this without attempting to 
follow up tlie details of the plan, which, of course, 
would be useless in a brief book-notice. We can 
only add that we feel confident the verdict of the 
profession will place Dr. Bartholow's 'Practice' 
among the standard text-books of the day." — Ci?i- 
ciiuiati Obstetric Gazette. 

"It is refreshing to turn from a work so crude 
and incomplete, so full of the exploded theories of 
by-gone days, as that of Professor Palmer, to the 
clear, lucid pages of Professor Bartholow. Pro- 
fessor Bartholow has won for himself so high a posi- 
tion as an original thinker and clear and forcible 
writer that any work from his pen would command 
attention and respect. One great charm of the 
writer is the intelligence and original thought which 
he brings to the discussion of every subject, and the 
directness, clearness, and vigor of his style. In his 
treatment he is much in advance of the leading 
writers of his school, and gives marked indications of 
having studied appreciatively some of the best writers 
of the new school." — Neiv York Medical Times. 

" The book is marked by an absence of all dis- 
cussion of the latest, fine-spun theories of points in 
pathology ; by the clearness with which points in 
diagnosis are stated ; by the conciseness and per- 
spicuity of its sentences ; by the abundance of the 
author's therapeutic resources ; and by the copious- 
ness of its illustrations." — Ohio Medical Recorder. 



D. APPLETON <S- CO.'S MEDICAL WORKS. >j 

ON THE ANTAGONISM BETWEEN MEDICINES 

AND BETWEEN REMEDIES AND DISEASES. Being the Cart- 
wright Lectures for the Year 1880. By Roberts Bartholow, M. A., 
M. D., LL. D., Professor of Materia Medica and General Therapeutics in 
the Jefferson Medical College of Philadelphia, etc., etc. 

I vol., 8vo. Cloth, $1.25. 

"We are g-lad to possess, in a form convenient no doubt that this, his latest contribution to medi- 

for reference, this most recent summary of the physi- cal science, will add materially to his previously high 

ological action of important remedies, with the de- reputation. Much profit, no little pleasure, and 

ductions of a careful and accomplished observer, re- material assistance in the solution of many thera- 

garding- the applications of this knowledge to dis- peutical problems are to be obtained from a perusal 

eased states." — College and Clinical Record. of these lectures. The author has done wisely and 

"There are few writers who have taken the conferred a boon by permitting their publication in 

trouble to compile the lucubrations of the multitude ^he present book-form, and we are satisfied it will 

of scribblers who find a specific in every drug they be extensively asked for, and just as extensively read 

happen to prescribe for a self-hmited, non-malig- ^^ appreciated. —Catiada Medical and Surgical 

nant disease ; and fewer who can detect the trashy Journal. 

chaff and garner only the ripe, plump grains. Tliis ' ' It will be observed that the scope of the work 

Bartholow has done, and no one is more ripe, nor is extensive, and, in justice to the author, not only 

better qualified for this herculean task ; and, the is the extent of this indicated, but the character of 

best of all is, condense it all in his antagonisms. it is also furnished. No one can read the synopsis 

No one can peruse its pregnant pages without no- given without being impressed with the importance 

ticing the painstaking research and large collection and diversity of the subjects considered. Indeed, 

of authorities from which he has drawn his conclu- most of the important forces in therapeutics and 

sions. The practitioner who purchases these antag- materia medica are herein stated and analyzed." — 

onisms will find himself better qualified to cope with American Medical Bi- Weekly. 
the multifarious maladies after its careful perusal." "Probably most of our readers will consider 

Indiana Medical Reporter. \hdX we have awarded this treatise high praise when 

"The criticisms made upon these lectures have we say that it seems to us the most carefully writ- 

invariably been most favorable, the topic itself is ten, best thought-out, and least dogmatic work 

one of the most interesting in the entire range of which we have yet read from the pen of its author, 

medicine, and it is treated of by the accomplished It is indeed a very praiseworthy book ; not an origi- 

author in a most scholarly manner. Dr. Bartholow nal research, indeed, but, as a resume of the world's 

worthily ranks as one of the best writers, while at work upon the subject, the best that has hitherto 

the same time one of the most diligent workers, in been published in any lang^uage." — Philadelphia 

the medical field in all America, and there can be Aledical Times. 

WINTER AND SPRING ON THE SHORES OF THE 

MEDITERRANEAN; or, the Genoese Rivieras, Italy, Spain, Corfu, 

Greece, the Archipelago, Constantinople, Corsica, Sicily, Sardinia, Malta, 

Algeria, Tunis, Smyrna, Asia Minor, with Biarritz and Arcachon, as Winter 

Climates. By James Henry Bennet, M. D., Member of the Royal College 

of Physicians, London, etc., etc. 

Fifth edition. With numerous Illustrations and Maps. I vol., i2mo, 655 pp. Cloth, $3.50. 

This work embodies the experience of fifteen winters and springs passed by Dr. Bennet on the 
shores of the Mediterranean, and contains much valuable information for physicians in relation to 
the health-restoring climate of the regions described. 

"We commend this book to our readers as a vol- once entertaining and instructive."— A't'i^ York 
ume presenting two capital quaUfications — it is at Medical Journal. 

ON THE TREATMENT OF PULMONARY CON- 
SUMPTION, by Hygiene, Climate, and Medicine, in its Connection with 
Modern Doctrines. By James Henry Bennet, M. D., Member of the 
Royal College of Physicians, London; Doctor of Medicine of the Uni- 
versity of Paris, etc., etc. 

I vol., tliin 8vo, 190 pp. Cloth, .$1.50. 

An interesting and instructive work, written in the strong, clenr, and lucid manner which ap- 
pears in all the c<jntributions of Dr. Bennet to medical or general literature. 

"We cordially commend this book to the at- temperate chmates, pulmonarj' consumption." — De- 
tention of all, for its practical, common-sense views troit Review of Medicine. 
of the nature and treatment of the scourge of all 



8 



D. APPLETON &- CO:S MEDICAL WORKS. 



GENERAL SURGICAL PATHOLOGY AND THERA- 
PEUTICS, in Fifty-one Lectures. A Text-Book for Students and Phy- 
sicians. By Dr. Theodor Billroth, Professor of Surgery in Vienna. 
With Additions by Dr. Alexander von Winiwarter, Professor of Surgery in 
Liittich, Translated from the fourth German edition with the special per- 
mission of the author, and revised from the tenth edition, by Charles E. 
Hackley, A. M., M. D., Physician to the New York and Trinity Hospitals ; 
Member of the New York County Medical Society, etc. 
I vol., 8vo, 835 pp. Cloth, $5.00; sheep, $6.00. 







^^^c:ffl 



:3^ " 

Giant-celled Sarcoma with Cysts and Ossifying Foci from the Lower Jaw. — Magnified 350 diameters. 

" Since this translation was revised from the sixth German edition in 1874, two other editions 
have been published. The present revision is made to correspond to the eighth German edition. 

" Lister's method of antiseptic treatment is referred to in various places, and other new points 
that have come up within a few years are discussed. 

"A chapter has been written on amputation and resection. In all, there are sevetity-fo7ir 
additional pages, with a number of woodcuts." — Extract from Translator' s Preface to the Revised 
Edition. 

" The want of a book in the English language, lure to say no book could more perfectly supply 
presenting in a concise form the views of the Ger- that want than the present volume." — The Lan- 
man pathologists, has long been felt, and we ven- cet. 

THE PHYSIOLOGICAL AND THERAPEUTICAL 

ACTION OF ERGOT. Being the Joseph Mather Smith Prize Essay for 

1881. By Etienne Evetzky, M. D, 

I vol., 8vo. Limp cloth, $1.00. 

"In undertaking the present work my object was to present in a condensed manner all the 
therapeutic possibilities of ergot. In a task of this nature, original research is out of the ques- 
tion. No man's evidence is sufficient to establish the merits of a drug considered in the manner 
indicated, and no one man's opportunities are sufficient to grasp the entire subject. Consequently 
it remained to gather from the volumes of past and current periodical literature the testimony of 
the multitude of physicians that had been led to use ergot in different morbid conditions. I have 
recorded everything that has come to my notice, I have grouped and classified the immense mate- 
rial in our possession. In all cases in M-hich the action of ergot could be explained, I have at- 
tempted to do so, although this task is frequently difficult, if not impossible. . . . The reader will 
see that ergot has been used in a large number of diseases ; some of these uses have little or no 
practical value, yet it is very important to know them, as they serve to illustrate the therapeutic 
properties of the drug. They have been brought to the notice of the reader without any com- 
ments, but those that are essential and of the greatest practical importance have been dealt with 
more fully. Among the latter may be mentioned the use of ergot in inflammation, aneurism, car- 
diac diseases, the post-parturient state, uterine fibroid tumors, rheumatism, etc." — Front Preface. 



D. APPLETON &- CO.'S MEDICAL WORKS. o 

OBSTETRIC CLINIC. A Practical Contribution to the Study 

of Obstetrics, and the Diseases of Women and Children, By George T. 

Elliot, M. D., late Professor of Obstetrics and Diseases of Women and 

Children in the Bellevue Hospital Medical College ; Physician to Bellevue 

Hospital and to the New York Lying-in Asylum, etc. 

I vol., 8vo, 458 pp. Cloth, $4.50. 

This work is, in a measure, a resume of separate papers previously prepared by the late Dr. 
Elliot ; and contains, besides, a record of nearly two hundred important and difficult cases in mid- 
wifery, selected from his own practice. The cases thus collected represent faithfully the diffi- 
culties, anxieties, and disappointments inseparable from the practice of obstetrics, as well as some 
of the successes for which the profession are entitled to hope in these arduous and responsible 
tasks. It has met with a hearty reception, and has received the highest encomiums both in this 
country and in Europe. 

THE SOURCE OF MUSCULAR POWER. Arguments 

and Conclusions drawn from Observations upon the Human Subject under 
conditions of Rest and of Muscular Exercise. By Austin Flint, Jr., M. D., 
Professor of Physiology in the Bellevue Hospital Medical College, New 
York, etc., etc. 

I vol., 8vo, 103 pp. Cloth, $1.00. 

" There are few questions relating to Philosophy of greater interest and importance than the 
one which is the subject of this essay. I have attempted to present an accurate statement of my 
own observations and what seem to me to be the logical conclusions to be drawn from them, as 
well as from experiments made by others upon the human subject under conditions of rest and of 
muscular exercise." — From the Preface. 

ON THE PHYSIOLOGICAL EFFECTS OF SEVERE 

AND PROTRACTED MUSCULAR EXERCISE. With special ref- 
erence to its Influence upon the Excretion of Nitrogen. By Austin Flint, 
Jr., M. D., Professor of Physiology in the Bellevue Hospital Medical Col- 
lege, New York, etc., etc. 

I vol., 8vo, 91 pp. Cloth, $1.00. 

This monograph on the relations of Urea to Exercise is the result of a thorough and careful 
investigation made in the case of Mr. Edward Payson Weston, the celebrated pedestrian. The 
chemical analyses were made under the direction of R. O. Doremus, M. D., Professor of Chem- 
istry and Toxicology in the Bellevue Hospital Medical College, by Mr. Oscar Loew, his assistant. 
The observations were made with the co-operation of J. C. Dalton, M. D., Professor of Physiol- 
ogy in the College of Physicians and Surgeons; Alexander B. Mott, M. D., Professor of Surgical 
Anatomy; W. H. Van Buren, M. D., Professor of Principles of Surgery; Austin Flint, M. D., 
Professor of the Principles and Practice of Medicine; W. A. Hammond, M. D., Professor of the 
Diseases of the Mind and Nervous System — all of the Bellevue Hospital Medical College. 

MANUAL OF CHEMICAL EXAMINATION OF THE 

URINE IN DISEASE. With Brief Directions for the Examination of 

the most Common Varieties of Urinary Calculi. By Austin Flint, Jr., 

M. D., Professor of Physiology and Microscopy in the Bellevue Hospital 

Medical College ; Fellow of the New York Academy of Medicine, etc. 

Fifth edition, revised and corrected, i vol., i2mo, 77 pp. Cloth, $1.00. 

The chief aim of this little work is to enable the busy practitioner to mnke for himself, rapidly 
and easily, all ordinarv examinations of Urine; to give him tlie benefit of the author's experience 
in eliminating little difficulties in the manipulations, and in reducing processes of analysis to the 
utmost simplicity that is consistent with accuracy. 

" We do not know of any work in F.mjiish so reputation of the author is a sufficient guarantee of 
complete and handy as the Manual now offered to the accuracy of all the directions given."— _7i;«;-Aiz/ 
the Profession by Dr. Flint, and the high scientific 0/ Applied. Chemistry. 



lO 



D. APPLETON &^ CO.'S MEDICAL WORKS. 



TEXT-BOOK OF HUMAN PHYSIOLOGY, for the Use 

of Students and Practitioners of Medicine. By Austin Flint, Jr., M. D., 
Professor of Physiology and Physiological Anatomy in the Bellevue Hospital 
Medical College, New York ; Fellow of the New York Academy of Medi- 
cine, etc. 
Third edition. Revised and corrected. In one large 8vo volume of 978 pp., elegantly printed on 

fine paper, and profusely illustrated with three Lithographic Plates and 315 Engravings on 

Wood, Cloth, $6.00; sheep, $7.00. 




"^tormch, Pancrea";, Large Intestine, etc 

" The author of this work takes rank among the 
very foremost physiolo.s;ists of the day, and the care 
which he has bestowed in bring-ing this third edition 
of his text-book up to the present position of his 
science is exhibited in every chapter." — Medical and 
Stirgical Reporter (P/n'ladelp/iia). 

" In the amount of matter that it contains, in 
the aptness and beauty of its illustrations, in the 
variety of experiments described, in the complete- 
ness with which it discusses the whole field of human 
physiology, this work surpasses any text-book in 
the English language." — Detroit Laticet. 

" The student and the practitioner, whose sound 
practice must be based on an intelligent appreciation 
of the principles of physiology, will herein find all sub- 
jects in which they are interested fully discussed and 
thoroughly elaborated." — College ayid Clin. Record. 

"We have not the slightest intention of criticis- 
ing the work before us. The medical profession 
and colleges have taken that prerogative out of the 



Longitudinal bection of the Human Larynx, 
showing the Vocal Cords. 



hands of the journalists by adopting it as one of 
their standard text-books. The work has very few 
equals and no superior in our language, and every- 
body knows it." — Halmemanman Monthly. 

" We need only say that in this third edition the 
work has been carefully and thoroughly revised. It 
is one of our standard text-books, and no physician's 
library' should be without it. We treasure it highly, 
shall give it a choice, snug, and prominent position 
on our shelf, and deem ourselves fortunate to pos- 
sess this elegant, comprehensive, and authoritative 
work. " — American Specialist. 

"Professor Flint is one of the most practical 
teachers of physiolog>' in this countrj', and his book 
is eminently like the man. It is very full and com- 
plete, containing practically all the established facts 
relating to the different subjects. This edition con- 
tains a number of important additions and changes, 
besides numerous corrections of slight typographical 
and other errors." — Oliio Medical Recorder. 



D. APPLETON &- CO:S MEDICAL WORKS. 



II 



THE PHYSIOLOGY OF MAN. Designed to represent the 

Existing State of Physiological Science as applied to the Functions of the 
Human Body. By Austin Flint, Jr., M. D., Professor of Physiology and 
Physiological Anatomy in the Bellevue Hospital Medical College, New- 
York ; Fellow of the New York Academy of Medicine, etc., etc. 
New and thoroughly revised edition. In 5 vols., 8vo. Per volume, cloth, $4.50; sheep, $5.50. 

Volume I. The Blood ; Circulation ; Respiration, 

Volume 11. Alimentation ; Digestion ; Absorption ; Lymph and Chyle. 

Volume III. Secretion ; Excretion ; Ductless Glands ; Nutrition ; Animal 

Heat; Movements; Voice and Speech. 
Volume IV. The Nervous System. 
Volume V. Special Senses ; Generation. 



"As a book of general information it will be 
found useful to the practitioner, and, as a book of 
reference, invaluable in the hands of the anatomist 
and physiologist." — Dublin Quarterly yournal of 
Medical Science. 

" Dr. Flint's reputation is sufficient to give a 
character to the book among the profession, where 
it will chiefly circulate, and many of the facts given 



have been verified by the author in his laboratory 
and in public demonstration." — Chicago Courier. 

" The author bestows judicious care and labor. 
Facts are selected with discrimination, theories crit- 
ically examined, and conclusions enunciated with 
commendable clearness and precision." — American 
yournal of the Medical Scie?ices. 



SYPHILIS AND MARRIAGE. Lectures delivered at the 

St. Louis Hospital, Paris. By Alfred Fournier, Professeur a la Faculte 
de Medecine de Paris ; Medecin de I'Hopital Saint-Louis. Translated by 
P. Albert Morrow, M. D., Physician to the Skin and Venereal Department, 
New York Dispensary, etc., etc. 

I vol., 8vo. Cloth, $2.00; sheep, $3.00. 



"The book supplies a want long recognized in 
medical literature, and is based upon a very ex- 
tended experience in the special hospitals for syphilis 
of Paris, which have furnished the author with a rich 
and rare store of cHnical cases, utilized by him with 
great discrimination, originality, and clinical judg- 
ment. It exhibits a profound knowledge of its sub- 
ject under all relations, united with marked skill and 
tact in treating the delicate social questions neces- 
sarily involved in such a line of investigation. The 
entire volume is full of information, mnemonically 
condensed into axiomatic 'points.' It is a book to 
buy, to keep, to read, to profit by, and to lend to 
others." — Boston Medical and Surgical fournal. 

" This work of the able and distinguished French 
syphilographer, Professor Fournier, is without doubt 
one of the most remarkable and important produc- 
tions of the day. Possessing profound knowledge 
of syphilis in all its protean forms, an unexcelled 
experience, a dramatic force of expression, untinged, 
however, by even a suspicion of exaggeration, and 
a rare tact in deahng with the most delicate prob- 
lems, he lias given to the world a series of lectures 
which, by their fascination of style, compels atten- 
tion, and by their profundity of wisdom carries con- 
viction." — .St. Louis Courier of Medicine and Col- 
lateral .Sciences. 

"Written with a perfect fairness, with a supe- 
rior ability, and in a style which, without aiming at 
effect, engages, interests, persuades, this work is one 
of those which ought to be immediately placed in 
the hands of every physician who desires not only 
to cure his patients, but to understand and fulfill his 
duty as an honest man." — Lyon Medicate. 

"No physician, who pretends to keep himself 



informed upon the grave social questions to which 
this disease imparts an absorbing interest, can afford 
to leave this valuable work unread." — St. Louis 
Clinical Record. 

" The author handles this grave social problem 
without stint. A general perusal of this work would 
be of untold benefit to society." — Louisville Medical 
Neivs. 

" The subject is treated by Professor Fournier in 
a manner that is above criticism. Exhaustive clini- 
cal knowledge, discriminating judgment, and thor- 
ough honesty of opinion are united in the author, 
and he presents his subject in a crisp and almost 
dramatic style, so that it is a positive pleasure to 
read the book, apart from the absolute importance 
of the question of which it treats." — iVezv York 
Medical Record. 

" Every page is full of the most practical and 
plain advice, couched in vigorous, emphatic lan- 
guage." — Detroit Lancet. 

" The subject here presented is one of the most 
important tliat can engage the attention of the pro- 
fession. The volume should be generally read, as 
the subject-matter is of great importance to society." 
— Maryland Medical fournal. 

"We can give only a very incomplete idea of 
this work of ^I. Fournier, wliich, by its precision, 
its clearness, by the forcilile manner in which the 
facts are grouped and presented, defies all analysis. 
' Syjjhilis and Marriage ' ought to be read by all 
physicians, who will find in it, first of all, science, 
but who will also find in it, during the hours they 
devote to its perusal, a charming literary [jleasure." 
— Annates de Dcrmatologie et de Syphiligraphie. 



12 



D. APPLETON &^ CO:S MEDICAL WORKS. 



CYCLOPAEDIA OF PRACTICAL RECEIPTS, and Col- 

lateral Information in the Arts, Manufactures, Professions, and Trades, 
including Medicine, Pharmacy, and Domestic Economy. Designed as a 
Comprehensive Supplement to the Pharmacopoeia, and General Book of 
Reference for the Manufacturer, Tradesman, Amateur, and Heads of Fam- 
ilies. Sixth edition, revised and partly rewritten by Richard V. Tuson, 
Professor of Chemistry and Toxicology in the Royal Veterinary College. 
Complete in 2 vols., 1,796 pp. With Illustrations. Cloth, $9.00. 

Cooley's "Cyclopaedia of Practical Receipts" has for many years enjoyed an extended reputa- 
tion for its accuracy and comprehensiveness. The sixth edition, now just completed, is larger 
than the last by some six hundred pages. Much greater space than hitherto is devoted to Hygiene 
(including sanitation, the composition and adulteration of foods), as well as to the Arts, Phar- 
macy, Manufacturing Chemistry, and other subjects of importance to those for whom the work is 
intended. The articles on what is commonly termed "Household Medicine" have been ampli- 
fied and numerically increased. 

The design of this work is briefly but not completely expressed in its title-page. Independ- 
ently of a reliable and comprehensive collection of formulae and processes in nearly all the indus- 
trial and useful arts, it contains a description of the leading properties and applications of the 
substances referred to, together with ample directions, hints, data, and allied information, cal- 
culated to facilitate the development of the practical value of the book in the shop, the laboratory, 
the factory, and the household. Notices of the substances embraced in the Materia Medica, in 
addition to the whole of their preparations, and numerous other animal and vegetable substances 
employed in medicine, as well as most of those used for food, clothing, and fuel, with their eco- 
nomic applications, have been included in the work. The synonyms and references are other addi- 
tions which will prove invaluable to the reader. Lastly, there have been appended to all the 
principal articles referred to brief but clear directions for determining their purity and commercial 
value, and for detecting their presence and proportions in compounds. The indiscriminate adop- 
tion of matter, without examination, has been uniformly avoided, and in no instance has any form- 
ula or process been admitted into this work, unless it rested on some well-known fact of science, 
had been sanctioned by usage, or come recommended by some respectable authority. 

THE COMPARATIVE ANATOMY OF THE DOMES- 
TICATED ANIMALS. By A. Chauveau, Professor at the Lyons Vet- 
erinary School. Second edition, revised and enlarged, with the co-operation 
of S. Arloing, late Principal of Anatomy at the Lyons Veterinary School; 
Professor at the Toulouse Veterinary School. Translated and edited by 
George Fleming, F. R. G. S., M. A. I., Veterinary Surgeon, Royal Engineers. 
I vol., 8vo, 957 pp. With 450 Illustrations. Cloth, $6.00. 



Specimen of Illustration 




"Taking it altogether, the book is a verj' wel- 
come addition to English Uterature, and great credit 
is due to Mr. Fleming for the excellence of the trans- 
lation, and the many additional notes he has ap- 
pended to Chauveau's treatise." — Lancet {Lo?tdo?t). 

" The descriptions of the text are illustrated and 



assisted by no less than 450 excellent woodcuts. In 
a work which ranges over so vast a field of anatomi- 
cal detail and description, it is difficult to select any 
one portion for review, but our examination of it 
enables us to speak in high terms of its general ex- 
cellence. . . ." — Medical Titnes and Gazette {Lon- 
don). 



D. APPLETON &- CO:S MEDICAL WORKS. 



13 



THE HISTOLOGY AND HISTO-CHEMISTRY OF 

MAN. A Practical Treatise on the Elements of Composition and Struc- 
ture of the Human Body. By Heinrich Frey, Professor of Medicine in 
Zurich, Translated from the fourth German edition, by Arthur E. J. Bar- 
ker, Surgeon to the City of Dublin Hospital ; Demonstrator of Anatomy, 
Royal College of Surgeons, Ireland ; and revised by the Author. With 680 
Engravings. 

I vol., 8vo, 683 pp. Cloth, $5; sheep, $6. 

CONTEA'TS.—The Elements 
of Composition and of Structure 
of the Body : Elements of Com- 
position — Albuminous or Protein 
Compounds, Hsemoglobulin, His- 
togenic Derivatives of the Albu- 
minous Substances or Albumi- 
noids, the P'atty Acids and Fats, 
the Carbo-hydrates, Non-Nitro- 
genous Acids, Nitrogenous Acids, 
Amides, Amido-Acids, and Or- 
ganic Bases, Animal Coloring 
Matters, Cyanogen Compounds, 
Mineral Constituents ; Elements 
of Structure — the Cell, the Origin 
of the Remaining Elements of 
Tissue; the Tissues of the Body 
— Tissues composed of Simple 
Cells, with Fluid Intermediate 
Substance, Tissues composed of 
Simple Cells, with a small amount 
of Solid Intermediate Substance, 
Tissues belonging to the Con- 
nective Substance Group, Tissues 

composed of Transformed and Transverse Section oi a Human Bone, 

as a rule, Cohermg Cells, with 

Homogeneous, Scanty, and more or less Solid Intermediate Substance ; Composite Tissues : The 
Organs of the Body — Organs of the Vegetative Type, Organs of the Animal Group. 




CONSERVATIVE SURGERY, as exhibited in remedying 

some of the Mechanical Causes that operate injuriously both in Health and 

Disease. With Illustrations. By Henry G. Davis, M. D., Member of the 

American Medical Association, etc., etc. 

I vol., 8vo, 315 pp. Cloth, $3. 

The author has enjoyed rare facilities for the study and treatment of certain classes of disease, 
and the records here presented to the profession are the gradual accumulation of over thirty years' 
investigation. 



" Dr. Da\'is, brinfjing- as he does to his specialty 
a great aptitude for the solution of mechanical prob- 
lems, takes a high ranli as an orthopedic surgeon, 
and his very practical contribution to the literature 
of the subject is both valuable and opportune. We 



deem it worthy of a place in every physician's li- 
brar)'. The style is unpretending, but trenchant, 
graphic, and, best of all, quite intelligible." — Medi- 
cal Recofd. 



YELLOW FEVER A NAUTICAL 

Origin and Prevention. By John Gamgee. 

I vol., 8vo, 207 pp. 

" The author discusses, with a vast array of clear 
and well-digested facts, the nature and prevention 
of yellow fever. The work is admirably written, 
and the author's theories plausible and well sus- 
tained by logical deductions from established facts." 
— Homoeopathic Times. 



DISEASE. Its 



Cloth, $1.50. 

" The theory is certainly shown to be a plausible 
one ; and every reader, whether he be convinced or 
not, can not but be interested, instructed, and set to 
thinking." — Lancet and Clinic. 



14 



D. APPLETON &^ CO.'S MEDICAL WORKS. 



Specimen of Illustration. 



CONTRIBUTIONS TO REPARATIVE SURGERY, show- 

ing its Application to the Treatment of Deformities, produced by Destruc- 
tive Disease or Injury; Congenital Defects from Arrest or Excess of Devel- 
opment ; and Cicatricial Contractions following Burns. Illustrated by Thirty 
Cases and fine Engravings. By Gurdon Buck, M. D. 

I vol., 8vo, 237 pp. Cloth, $3. 

"There is no department of surgery where the ingenuity 
and skill of the surgeon are more severely taxed than when 
required to repair tlie damage sustained by the loss of parts, 
or to remove the disfigurement produced by destructive dis- 
ease or violence, or to remedy the deformities of congenital 
malformation. The results obtained in such cases within 
the last half-century are among the most satisfactory achieve- 
ments of modern surgery. The term • Reparative Surgery ' 
chosen as the title of this volume, though it may, in a com- 
prehensive sense, be applied to the treatment of a great 
variety of lesions to which the body is liable, is, however, 
restricted in this work exclusively to what has fallen under 
the author's own observation, and has been subjected to the 
test of experience in his own practice. It largely embraces 
the treatment of lesions of the face, a region in which plastic 
surgery finds its most frequent and important applications. 
Another and no less important class of lesions will also be 
found to have occupied a large share of the author's atten- 
tion, viz., cicatricial contractions following burns. AVhile 
these cases have a very strong claim upon our commisera- 
tion, and should stimulate us, as surgeons, to the greatest 
efforts for their relief, they have too often in the past been 
dismissed as hopelessly incurable. The satisfactory results 
obtained in the cases reported in this volume will encour- 
age other surgeons, we trust, to resort with greater hope- 
fulness in the future to operative interference. Accuracy 
of description and clearness of statement have been aimed 
at in the following pages ; and if, in his endeavor to attain 
this important end, ihe author has incurred the reproach of 
tediousness, the difficulty of the task must be his apology." 
— Extract from Preface. 




THE CHEMISTRY OF COMMON LIFE. Illustrated 
with numerous Wood Engravings. By the late James F. W. Johnson, 
F. R. S., Professor of Chemistry in the University of Durham. A new 
edition, revised and brought down to the Present Time. By Arthur Her- 
bert Church, M. A., Oxon. 
Illustrated with Maps and numerous Engravings on Wood. In one vol., i2mo, 592 pp. $2. 

SUMMARY OF CONTENTS.— 'Y'^& Kxr \vq Breathe; the Water we Drink; the Soil we 
Cultivate ; the Plant we Rear ; the Bread we Eat ; the Beef we Cook ; the Beverages we Infuse ; 
the Sweets we Extract ; the Liquors we Ferment ; the Narcotics we Indulge in ; the Poisons we 
Select; the Odors we Enjoy ; the Smells we Dislike; the Colors we Admire; What we Breathe 
and Breathe for; What, How, and Why we Digest; the Body we Cherish; the Circulation of 
Matter. 

THE TONIC TREATMENT OF SYPHILIS. By E. L. 

Keyes, a. M., M. D., Adjunct Professor of Surgery and Professor of Der- 
matology in the Bellevue Hospital Medical College, etc. 

I vol., 8vo, 83 pp. Cloth, $1. 

'* My studies in syphilitic blood have yielded results at once so gratifying to me, and so con- 
vincing as to the tonic influence of minute doses of mercury, that I feel impelled to lay this brief 
treatise before the medical public in support of a continuous treatment of syphilis by small (Ionic) 
doses of mercury. I believe that a general trial of the method will, in the long run, vindicate its 
excellence. ' ' — Extract from Preface. 



D. APPLETON (S- CO:S MEDICAL WORKS. 



15 



A PRACTICAL TREATISE ON TUMORS OF THE 

MAMMARY GLAND : embracing their Histology, Pathology, Diagnosis, 
and Treatment. By Samuel W. Gross, A. M., M. D., Surgeon to, and 
Lecturer on Clinical Surgery in, the Jefferson Medical College Hospital 
and the Philadelphia Hospital, etc. 



In one handsome 8vo vol. of 246 pp., with 29 Ilhistrations. Cloth, $2.50. 



"The work opportunely supplies a real want, 
and is tlie result of accurate work, and we heartily 
recommend it to our readers as well worthy of care- 
ful study." — London Lancet. 

" We know of no book in the English langniag-e 
which attempts to cover the ground covered by tiiis 
one — indeed, the author seems to be the first who has 
sought to handle the whole subject of mammary 
tumors in one systematic treatise. How he has suc- 
ceeded will best be seen by a study of the book itself. 
In the early chapters the classification and relative 
frequency of the various tumors, their evolution and 
transformations, and their etiology, are dealt with ; 
then each class is studied in a separate chapter, in 
which the result of the author's work is compared 
with that of others, and the general conclusions are 
drawn which give to the book its great practical 
value ; finally, a chapter is devoted to diagnosis, one 
to treatment, and one to the tumors in the mam- 
mary gland of the male." — Neuj York Medical 
yournal. 

"We heartily commend this work to the profes- 
sion, knowing that those who study its pages will 
be well repaid and have a better understanding of 
what to the average practitioner is obscure and un- 
satisfactory." — Toledo Medical and Sui-gical jfour- 
nal. 

' ' Dr. Gross has produced a work of real and 
permanent value ; it is not overstating the truth to 
say that this little volume is probably the best con- 
tribution to medical science which the present year 
has brought forth. We believe that the author has 








Development oi Carcinoma. 



Cystic Encephaloid Carcinoma. 

done what he has set out to do, viz. , constructed a 
systematic and strictly accurate treatise on mammary 
tumors, and brought to his task all the light afforded 
by the most recent investigations into their pathol- 
ogy." — St. Louis Clinical Record. 

" This book is a real contribution to our profes- 
sional literature ; and it comes from a source which 
commands our respect. The plan is very systematic 
and complete, and the student or practitioner alike 
will find exactly the information he seeks upon any 
of the diseases which are incident to the mammary 
gland." — Obstetrical Gazette. 

" Altogether, the work is one of more than ordi- 
nary interest to the surgeon, gynaecologist, and phy- 
sician." — Detroit Laiicet. 

"The work is at once original, scientific, and 
practical. Its histology will receive the careful at- 
tention of the specialist ; the surgeon will find it a 
guide and help ; while the general practitioner, who 
would be informed, and desires to know what will 
be taught in our text-books and in our colleges, 
must study it. It is an effort that will add new 
honor to an honorable name, and of which we, as 
h mericans, may all be proud as an example of origi- 
nal work and investigation." — Buffalo Medical and 
Surgical yournal. 

"Dr. Gross has given to the profession, in his 
' Treatise on Tumors of the Mammary Gland,' one 
of the most useful and original surgical works of the 
nineteenth century. It is but honest and just praise 
to say that in this treatise the author shows himself 
the intellectual peer of his great father, America's 
great surgeon." — Louisville Medical News. 

"A treatise based upon the systematic analysis 
of so large an amount of material can not fail to 
recommend itself to the intelligent surgeon, espe- 
cially as it, so far as we know, is the only recent 
work published which affords any trustworthy in- 
formation on this important subject. The author 
shows an intimate knowledge of the investigations 
of others, and refers to them frequently throughout 
the work, a fact which materially adds to its value." 
— Philadelphia Medical and Surgical Reporter. 

" He deserves the thanks of the profession for 
his bold and direct opinions, and doubtless in the 
future the general surgical practitioner will attack 
these tumors with more painstaking, and with more 
confidence in the results." — North Caroli?ia Medi- 
cal yournal. 



i6 



D. APPLETON &- CO.'S MEDICAL WORKS. 



EMERGENCIES, AND HOW TO TREAT THEM. 

The Etiology, Pathology, and Treatment of Accidents, Diseases, and Cases 
of Poisoning, which demand Prompt Action. Designed for Students and 
Practitioners of Medicine. By Joseph W. Howe, M. D., Clinical Profess- 
or of Surgery in the Medical Department of the University of New York, 

etc., etc. 

Fourth edition, revised, i vol., 8vo, 265 pp. Cloth, $2.50. 

book we recommend it most heartily to the profes- 
sion." — Boston Medical aitd Surgical Journal. 

" This work bears evidence of a thorough prac- 
tical acquaintance with the different branches of the 
profession. The author seems to possess a peculiar 
aptitude for imparting instruction as well as for 
simplifying tedious details. A careful perusal will 
amply repay the student and practitioner." — New 
York Medical Jouriial. 



" To the general practitioner in towns, \-illages, 
and in the countrj', where the aid and moral sup- 
port of a consultation can not be availed of, this 
volume will be recognized as a valuable help. We 
commend it to the prof ession. " — Cincinnati Lancet 
and Observer. 

' ' The author wzistes no words, but devotes him- 
self to the description of each disease as if the pa- 
tient were under his hands. Because it is a good 



A TREATISE ON THE DISEASES OF THE NERV- 
OUS SYSTEM. By William A. Hammond, M. D., Surgeon-General 
U. S. Army (retired list) ; Professor of Diseases of the Mind and Nervous 
System, in the New York Post-Graduate Medical School ; President of the 
American Neurological Association, etc. 

Seventh edition, rewritten, enlarged and improved. In one large 8vo vol. of 929 pp., with Com- 
plete Index and 150 Illustrations. Cloth, $5 ; sheep or half russia, $6. 

Specimen of Illustration. This, the seventh edition of 

Dr. Hammond's well-known 
work, has been thoroughly re- 
vised, and enlarged by the ad- 
dition of new chapters, and of 
a section on Diseases of the 
Sympathetic System. 

The work has received the 
honor of a French translation 
by Dr. Labadie-Lagrave, of 
Paris, and an Italian transla- 
tion by Professor Diodato Bor- 
relli, of the Royal University, 
is now going through the press 
at Naples. 

' ' Dr. Hammond's work has 
now been before the profession 
for many years, and its charac- 
teristics are ver)' generally known. 
The present edition has a good 
many valuable additions, but has 
lost nothing of its previous indi- 
viduality as a medical work. Dr. Hammond has the qualities of a successful author. His practical ex- 
perience is large, his convictions are positive, and he can set them forth clearly and attractively. It is not 
surprising that his book has been a very popular one. And the present edition is, as modestly stated on 
the title-page, ' improved.' " — Medical Record. 

" This is unquestionably the most complete trea- 
tise on the diseases to which it is devoted that has 
yet appeared in the English language ; and its value 
is much increased by the fact that Dr. Hammond 
has mainly based it on his own experience and prac- 
tice, which, we need hardly remind our readers, 
have been verj' extensive." — Medical Times and 
Gazette. 

"The author is a concise writer, who never 
wastes any paper, and he has, as he says himself in 
his preface, views of his own on ever}' disease con- 
sidered, and he is not afraid to express them ; in 
short, the work is largely the result of his own ob- 
servation and experience, though the labors of others 
are by no means ignored." — Medical and Surgical 
Reporter, Philadelphia. 




" It ever3r\vhere e\nnces comprehensive apprecia- 
tion of the scope of the subjects considered, offering 
what is known and at the same time indicating the 
paths by which further obsenation will lead to more 
perfect knowledge. It is a reliable guide to the 
study and treatment of a most highly interesting^ 
class of diseases, and will unquestionably maintain 
if not extend in its present form the approbation 
and appreciation its merits have hitherto com- 
manded." — New York Medical Gazette. 

" The merits of this book, like those of its au- 
thor, have not been hid under a bushel. It shows 
great facility of expression, much thought, and wide 
reading, with an uncommon faith in the power of 
remedies over diseases commonly found intraci- 
able." — Louisville Medical News. 



D. APPLETON &^ CO:S MEDICAL WORKS. 



17 



" . , . We have only to wish this book a con- 
tinuance of its well-deserved popularity, and to 
recommend it to our readers as a work which any 
one who has to do with nervous diseases can not 
well afford to be without." — Dublin Medical Jour- 
nal. 

"Our space, and indeed the very nature of the 
work, forbids a detailed notice of the book. Suffice 
it to say that we are convinced, from a by no means 
superficial examination of it, that there is no work 
on the subject better adapted to the wants of the 
general practitioner at least." — Michigan Medical 
News. 

"We regard Dr. Hammond's work as excellent 
authority on the subject of nervous diseases, and 
frequently refer to it in our study of these affec- 
tions." — Caitada Lancet. 

" Dr. Hammond's book is the only complete one 
on nervous diseases accessible to the English-read- 
ing student, which is the work of a competent writ- 
er, one who has observed, studied, and treated 
these affections himself." — .5"/. Louis Clinical Rec- 
ord. 

" A careful examination shows this to be essen- 
tially a new volume, and the rewriting and remod- 
eling having wrought such changes, that it will be 
consulted with an increased degree of confidence by 
general practitioners." — North Carolina Medical 
Journal. 



Specimen of Illustration. 



iLiirf^»^ ^^' 




CLINICAL LECTURES ON DISEASES OF THE 

NERVOUS SYSTEM. Delivered at the Bellevue Hospital Medical Col- 
lege. By William A. Hammond, M. D., Professor of Diseases of the Mind 
and Nervous System, etc. Edited, with Notes, by T. M. B. Cross, M. D., 
Assistant to the Chairs of Diseases of the Mind and Nervous System, etc. 
In one handsome volume of 300 pages. $3.50. 

These lectures have been reported in full, and, together with the histories of the cases, which 
were prepared by the editor after careful study and prolonged observation, constitute a clinical 
volume which, while it does not claim to be exhaustive, will nevertheless be found to contain 
many of the more important affections of the kind that are commonly met with in practice. 

As these lectures were intended especially for the benefit of students, the author has confined 
himself to a full consideration of the symptoms, causes, and treatment of each affection, without 
attempting to enter into the pathology or morbid anatomy. 



THE ANATOMY OF VERTEBRATED ANIMALS. 

By Thomas Henry Huxley, LL. D., F. R. S. 

I vol., i2mo. Illustrated. 431 pp. Cloth, $2.50. 

" The present work is intended to provide students of comparative anatomy with a condensed 
statement of the most important facts relating to the structure of vertebrated animals which have 
hitherto been ascertained. The Vertebrata are distinguished from all other animals by the circum- 
stance that a transverse and vertical section of the body exhibits two cavities completely separated 
from one another by a partition. The dorsal cavity contains the cerebro-spinal nervous system ; 
the ventral, the alimentary canal, the heart, and usually a double chain of ganglia, which passes 
under the name of the ' sympathetic. ' It is probable that this sympathetic nervous system repre- 
sents, wholly or partially, the principal nervous system of the Anniilosa and Mo/htsca. And, in 
any case, the central parts of the cerebro-spinal nervous system, viz., the brain and the spinal 
cord, would appear to be unrepresented among invertebraled animals." — 77/t' Aiitlior. 

"This long-expected work will be cordially wel- It is enough to say that it realizes, in a remarkable 

comed by all students and teachers of Comparative degree, the anticipations which have been formed 

Anatomy as a compendious, reliable, and, notwith- of it ; and that it presents an extraordinary combi- 

standing its small dimensions, most comprehensive nation of wide, general views, with the clear, accu- 

guide on the subject of which it treats. To praise rate, and succinct statement of a prodigious number 

or to criticise the work of so accomplished a master of individual facts." — Nature. 
of his favorite science would be equally out of place. 



i8 



D. APPLETON &- CO.'S MEDICAL WORKS. 



A TREATISE ON ORAL DEFORMITIES, as a Branch 
of Mechanical Surgery. By Norman W. Kingsley, M. D. S., D. D. S., 
President of the Board of Censors of the State of New York, late Dean of 
the New York College of Dentistry and Professor of Dental Art and Mech- 
anism, etc., etc. 

With over 350 Illustrations. One vol., 8vo. Cloth, $5 ; sheep, $6. 



Specimen of iLLVSTnATiON. 




>^^>*x--J.J5;^, \\A\, 



" I have read with great pleasure and much 
profit your valuable ' Treatise on Oral Deformi- 
ties.' The work contains much original matter 
of great practical value, and is full of useful in- 
formation, which will be of great benefit to the 
profession." — Lewis A. Sayre, M. D., LL. D., 
Professor of Orthopedic Surgery and Clinical 
Surgery, Bellevue Hospital Medical College. 

"A casual glance at this work might impress 
the reader with the idea that its contents were of 
more practical value to the dentist than to the 
general practitioner or surgeon. But it is b)' no 
means a mere work on dentistrj', although a prac- 
tical knowledge of the latter art seems to be es- 
sential to the carr)'ing out of the author's views 
regarding the correction of the different varieties 
of oral deformities of which he treats. We would 
be doing injustice to the work did not we make 
particular reference to the masterly chapter on the 
treatment of fractures of the lower jaw. The 
whole subject is so thoroughly studied that noth- 
ing is left to be desired by any surgeon who wish- 
es to treat these fractures intelligently and success- 
fully. The work, as a whole, bears marks of 
originality in every section, and impresses the 
reader with the painstaking efforts of the author 
to get at the truth, and apply it in an ingenious 
and practical way to the wants of the general 
practitioner, the surgeon, and the dentist." — 
Medical Record. 

"The profession is to be congratulated on 
possessing so valuable an addition to its litera- 
ture, and the author to be unstintedly praised for his successful issue to an arduous undertaking. The work 
bears, in a word, every evidence of having been written leisurely and with care. . . .''—Dental Cosmos. 

" To the surgeon and general practitioner of medicine, as well as the dentist, its instruction will be 

found invaluable. It is clear in style, practical in its application, comprehensive in its illustrations, and so 

exhaustive that it is not likely to meet in these respects a rival."— William H. Dwinelle, A. M., M. D. 

" I consider it to be the most valuable work that has ever appeared in this country in any department 

of the science of dental surger^^ 

"There is no doubt of its great value to every man who wishes to study and practice this branch 
of surgery, and I hope it may be adopted as a text-book in every dental college, that the students may 
have the benefit of the great e.xperience of the 
author. 

" It places many things between the covers of 
one book which heretofore I have been obliged to 
look for in many directions, and often without 
success." — Frank Abbot, M. D., Dean of the 
New York College of Dentistry. 

"The writer does not hesitate to express his 
belief that the chapters on the ' aesthetics of den- 
tistry ' will be found of more practical value to 
the prosthetic dentist than all the other essays 
on tills subject existent in the English language. 
... A perusal of its pages seems to compel the 
mind to advance in directions variously indi- 
cated ; so variously, indeed, that there is hardly 
a page of the book which does not contain some 
important truth, some pregnant hint, or some 
valuable conclusion." — Dental Miscellany. 

" I congratulate you on having written a 
book containing so much valuable and original 
matter. It will prove of value not only to den- 
tists, but also to surgeons and physicians." — 
Frank Hastings Hamilton, M. D., LL. D., 
Professor of the Practice of Surgery ivith Opera- 
tions, and of Clinical Surgery in Bellevue Hos- 
pital Medical College. 



Specimen of Illustration. 




D. APPLETON &- CO.'S MEDICAL WORKS. 



19 



THE BREATH, AND THE DISEASES WHICH GIVE 

IT A FETID ODOR. With Directions for Treatment. By Joseph W. 
Howe, M. D., Clinical Professor of Surgery in the Medical Department of 
the University of New York, etc. 

Second edition, revised and corrected. I vol., i2mo, 108 pp. Cloth, $1. 

' ' This little volume well deserves the attention 
of physicians, to whom we commend it most high- 
ly." — Chicago Medical Journal. 

" To any one suffering from the affection, either 
in his own person or in that of his intimate ac- 
quaintances, we can commend this volume as con- 
taining all that is known concerning the subject, set 



forth in a pleasant style." — Philadelphia Medical 
Times. 

" The author gives a succinct account of the dis- 
eased conditions in which a fetid breath is an im- 
portant symptom, with his method of treatment. 
We consider the work a real addiiion to medical lit- 
erature." — Cincinnati Medical Jom-nal. 



ON THE BILE, JAUNDICE, AND BILIOUS DIS- 
EASES. By J. WiCKHAM Legg, M. D., F. R. C. S., Assistant Physician to 
St. Bartholomew's Hospital, and Lecturer on Pathological Anatomy in the 
Medical School. 

In one volume, 8vo, 719 pp. With Illustrations in Chromo-lithography. Cloth, $6; sheep, $7. 



"... And let us turn — which we gladly do — to 
the mine of wealth which the volume itself contains, 
for it is the outcome of a vast deal of labor ; so 
great indeed, that one unfamiliar with it would be 
surprised at the number of facts and references 
which the book contains." — Medical Times and Ga- 
zette, London. 

" The book is an exceedingly good one, and, in 
some points, we doubt if it could be made better. 
. . . And we venture to say, after an attentive 
perusal of the whole, that any one who takes it 
in hand will derive from it both information and 
pleasure ; it gives such ample evidence of honest 
hard work, of wide reading, and an impartial at- 
tempt to state the case of jaundice, as it is known 
by observation up to the present date. The book 
will not only live, but be in the enjoyment of a vig- 
orous existence long after some of the more popular 
productions of the present age are buried, past all 
hope of resurrection. "-r-Z-o^t/wz Medical Record. 

" This portly tome contains the fullest account 
of the subjects of which it treats in the English lan- 
guage. The historical, scientific, and practical de- 
tails are all equally well worked out, and together 
constitute a repertorium of knowledge which no 
practitioner can well do without. The illustrative 
chromo-lithographs are beyond all praise," — Edin- 
burgh Medical yournal. 



" Dr. Legg's treatise is a really great book, ex- 
hibiting immense industry and research, and full of 
valuable information." — American Journal of Med- 
ical Science. 

"It seems to us an exhaustive epitome of all 
that is known on the subject." — Philadelphia Medi- 
cal Times. 

"This volume is one which will command pro- 
fessional respect and attention. It is, perhaps, the 
most comprehensive and exhaustive treatise upon 
the subject treated ever published in the English 
langfuage." — Maryland Medical Journal. 

" It is the work of one who has thoroughly stud- 
ied the subject, and who, when he finds tlie evi- 
dence conflicting on disputed points, has attempted 
to solve the problem by experiments and observa- 
tions of his owxi.."— Practitioner , London. 

"It is a valuable work of reference and a wel- 
come addition to medical literature. — Dublin Jour- 
nal of Medical Science. 

"... The reader is at once struck with the im- 
mense amount of research exhibited, the author 
having left unimproved no accessible source of in- 
formation connected with his subject. It is, indeed, 
a valuable book, and the best storehouse of knowl- 
edge in its department that we know of." — Pacific 
Medical atid Surgical Journal. 



FIRST LINES OF THERAPEUTICS as Based on the 

Modes and the Processes of Healing, as occurring spontaneously in Dis- 
eases ; and on the Modes and the Processes of Dying as resulting naturally 
from Disease. In a Series of Lectures. By Alexander Harvey, M. A., 
M. D., Emeritus Professor of Materia Medica in the University of Aber- 
deen, etc., etc. 

I vol., I2mo, 278 pp. Clotli, $1.50. 



" If only it can get a fair hearing before the pro- 
fession it will be tlie means of aiding in the devel- 
opment of a therapeutics more rational than we 
now dream of. To medical students and practi- 
tioners of all sorts it will open up lines of thought 
and investigation of the utmost moment." — Detroit 
Lancet. „ 



"We may say tliat, as a contribution to the 
pliilosophy of medicine, this treatise, which may be 
profitably read during f)dd mf)ments of leisure, has 
a happy metliod of statement and a refreshing free- 
dom from dogmatism." — Xezu Vorh Medical Rec- 
ord. 



20 



D. APPLETON &- CO:S MEDICAL WORKS. 



THE SCIENCE AND ART OF MIDWIFERY. By 

William Thompson Lusk, M. A., M. D., Professor of Obstetrics and Dis- 
eases of Women and Children in the Bellevue Hospital Medical College ; 
Obstetric Surgeon to the Maternity and Emergency Hospitals ; and Gynae- 
cologist to the Bellevue Hospital. 

Complete in one volume, 8vo, with 226 Illustrations. Cloth, $5 ; sheep, $6. 

" It contains one of the best ex> 
positions of the obstetric science and 
practice of the day with which we 
are acquainted. Throughout the 
work the author shows an intimate 
acquaintance with the literature of 
obstetrics, and gives evidence of large 
practical experience, great discrimi- 
nation, and sound judgment. We 
heartily recommend the book as a 
full and clear exposition of obstetric 
science and safe guide to student and 
practitioner." — London Lancet. 

" Professor Lusk's book presents 
the art of midwifery with all that 
modem science or earlier learning 
has contributed to it." — Aledical 
Record^ New York. 

"This book bears evidence on 
every page of being the result of 
patient and laborious research and 
great personal experience, united 
and harmonized by the true critical 
or scientific spirit, and we are con- 
vinced that the book will raise the 
D'Outreponfs Method, m6dlfied by Scanzoni. general standard of obstetric knowl- 

edge both m his own country and 
in this. Whether for the student obliged to learn the theoretical part of midwifery, or for the busy prac- 
titioner seeking aid in face of practical difficulties, it is, in our opinion, the best modern work on mid- 
wifery in the English language." — Dublin Journal 0/ Medical Scieiice. 





Author's Modification of Tamier's Forceps, 



" Dr. Lusk's style is clear, generally concise, and 
he has succeeded in putting in less than seven hun- 
dred pages the best exposition in the English lan- 
guage of obstetric science and art. The book will 
prove invaluable alike to the student and the prac- 
titioner." — American Practitioner. 

" Dr. Lusk's work is so comprehensive in design 
and so elaborate in execution that it must be recog- 
nized as having a status peculiarly its own among 
the text-books of midwifery in the English lan- 
guage." — New York Medical Journal. 

"The work is, perhaps, better adapted to the 
wants of the student as a text-book, and to the 
practitioner as a work of reference, than any other 
one publication on the subject. It contains about 
all that is known of the ars obstetrica, and must 
add greatly to both the fame and fortune of the 
distinguished author." — Medical Herald, Louis- 
ville. 



"Dr. Lusk's book is eminently viable. It can 
not fail to live and obtain the honor of a second, a 
third, and nobody can foretell how many editions. 
It is the mature product of great industry and acute 
observation. It is by far the most learned and most 
complete exposition of the science and art of obstet- 
rics written in the English language. It is a book 
so rich in scientific and practical information, that 
nobody practicing obstetrics ought to deprive him- 
self of the advantage he is sure to gain from a fre- 
quent recourse to its Y>3^g&s:''— American Journal 0/ 
Obstetrics. 

"It is a pleasure to read such a book as that 
which Dr. Lusk has prepared ; everything pertain- 
ing to the important subject of obstetrics is dis- 
cussed in a masterly and captivating manner. We 
recommend the book as an excellent one, and feel 
confident that those who read it will be amply xe- 
■pa-id."— Obstetric Gazette, Cincinnati. 



D. APPLETON (S- CO:S MEDICAL WORKS. 



21 



"To consider the work in detail 
would merely involve us in a reitera- 
tion of the high opinion we have al- 
ready expressed of it. What Spiegel- 
berg has done for Germany, Lusk, 
imitating him but not copying him, 
has done for English readers, and we 
feel sure that in this country, as in 
America, the work will meet with a 
very extensive approval." — Edinburgh 
Medical yournal. 

" The whole range of modern ob- 
stetrics is gone over in a most system- 
atic manner, without indulging in the 
discussion of useless theories or con- 
troversies. The style is clear, concise, 
compact, and pleasing. The illustra- 
tions are abundant, excellently exe- 
cuted, remarkably accurate in outline 
and detail, and, to most of our Ameri- 
can readers, entirely fresh." — Cincin- 
nati Lancet and Clinic. 



"We thank Dr. Lusk for his most 
valuable work, which is, in our opin- 
ion, as we have said before, the best 
representative of the state of obstetric 
science and art at the present day that 
exists in the English language. Stu- 
dent and practitioner will alike find it suitable to their needs, and there are few specialista who will 
not gain instruction from it." — Medical Times and Gazette, London. 

"This is undoubtedly the best book on the sub- "A work which, like the one before us, com- 

ject in the language. It is written from a physio- bines the qualities of being a safe and reliable guide 




Appearance of Cervix in Multipara; Ninth Month. 



logical stand-point, combined with an extended 
clinical knowledge. It is evident that teachers of 
obstetrics will not only be glad to commend such a 
work to their pupils, but will find it a most valuable 
guide for themselves." — Chicago Medical Review. 



to the practitioner, at the same time that it presents 
to the reader a fair statement of the labors of recent 
investigators, can not but prove useful." — Medical 
and Surgical Reporter , Philadelphia. 



HEALTH PRIMERS. Edited by J. Langdon Down, M. D., 
F. R. C. P. ; Henry Power, M. B., F. R. C. S. ; J. Mortimer-Granville, 
M. D. ; John Tweedy, F. R. C. S. 

In square l6mo volumes. Cloth, 40 cents each. 

Though it is of the greatest importance that books upon health should be in the highest degree 
trustworthy, it is notorious that most of the cheap and popular kind are mere crude compilations 
of incompetent persons, and are often misleading and injurious. Impressed by these considera- 
tions, several eminent medical and scientific men of London have combined to prepare a series of 
Health Primers of a character that shall be entitled to the fullest confidence. They are to be 
brief, simple, and elementary in statement, filled with substantial and useful information suitable 
for the guidance of grown-up people. Each primer will be written by a gentleman specially com- 
petent to treat his subject, while the critical supervision of the books is in the hands of a commit- 
tee who will act as editors. 

As these little books are produced by English authors, they are naturally based very much 
upon English experience, but it matters little whence illustrations upon such subjects are drawn, 
because the essential conditions of avoiding disease and preserving health are to a great degree 
everywhere the same. 

Volumes now ready. 

I. Exercise and Training. 

II. Alcohol : its Use and Abuse. 

III. Premature Death: its Promotion and Prevention. 

IV. The House and its Surroundings. 

V. Personal Appearance in Health and Disease. 
VI. Baths and Bathing. 
VII. The Skin and its Troubles. 
VIII. The Heart and its Functions. 
IX. The Nervous System. 



22 D- APPLETON C-^ CO.'S MEDICAL WORKS. 

ANALYSIS OF THE URINE. With Special Reference to 
the Diseases of the Genito-Urinary Organs. By M. B. Hoffman, Professor 
in the University of Gratz, and R. Ultzimann, Decent in the University of 
Vienna. Translated from the German edition under the special super- 
vision of Dr. Ultzmann. By T. Barton Brune, A. M., M. D., Resident 
Physician Maryland University Hospital, and H. Holbrook Curtis, Ph. B. 
With Eight Lithographic Colored Plates from Ultzmann and Hoffman's 
Atlas, and from Photographs furnished by Dr. Ultzmann, which do not 
appear in the German edition or any other translation. 

I vol., 8vo, 200 pages. $2. 

"We have not space for further analysis of the sis of the urine and diseases of the kidney, it ad- 

wrork, but would simply state that it well deserves mirably well fulfills the purpose of its being, viz., 

the reputation it has already obtained abroad. It is to concisely yet clearly present to the student an ac- 

eminently practical, and adapted, as the authors count of the normal and abnormal constituents of 

claim, to the wants of the physician and student the urine, the methods of their detection, and of 

rather than of the medical chemist, although the their diagnostic significance in general and local 

latter can ill afford to dispense with it." — Philadel- disease." — Southern Practitioner, 
pliia Medical Times. .< -^Ve indorse the statement that the book is fully 

"At the present time we are unacquainted with up to the times, and heartily recommend it to stu- 
any work at all equal to this in meeting the needs dents and practitioners of medicine as the most use- 
of the medical student. The elegant form in which ful and concise book on the subject. The practi- 
the publishers have issued it adds still further to its tioner, when he reads this little book, will be as- 
desirable qualities." — Detroit Lancet. tonished at the simplicity of ordinary urinalyses, 

' ' Throughout, the book is characterized by sound and, instead of sending to experts, will save time 

doctrine, scientific accuracy, and careful compila- and trouble by makmg them for himself. —Loius- 

tion ; while, as a translation from a foreign tongue, 'i-'itle Medical News. 

its lucidity of style, terseness, and perspicuity are " An examination of the book satisfies us that it 

veritably surprising. It can not fail, in our opin- has been carefully prepared, and can be relied on 

ion, to attain the end set before its authors in its for correctness. The new chemical notation is used, 

preparation, and prove a most valuable aid alike to and also the metrical system of weights and meas- 

student and practitioner in the urological diagnosis ures. As an appendix to the text, eight colored 

and study of disease. Eight very good double plates illustrate the solid constituents of the urine, 
plates, portraying the microscopic deposits of the ..Qn the whole, we regard the book as well 

urine, complete the book."— Cawaa'a Journal of adapted to its purpose, and a decided convenience 

Medical Science. to the practitioner who aims at something beyond 

" We advise our readers to procure the Apple- guess-work in diagfnosis and prognosis of urinary 

tons' edition by all means ; making no pretensions disorders." — New York Medical and Surgical 

to be an exhaustive treatise on the subject of analy- yournal. 

CLINICAL ELECTRO-THERAPEUTICS. (Medical and 

Surgical.) A Manual for Physicians for the Treatment more especially of 

Nervous Diseases. By Allan McLane Hamilton, M. D., Physician in 

charge of the New York State Hospital for Diseases of the Nervous System, 

etc., etc. 

With numerous Illustrations. I vol., 8vo. Cloth, $2. 

This work is the compilation of well-tried measures and reported cases, and is intended as a 
simple guide for the general practitioner. It is as free from confusing theories, technical terms, 
and unproved statements as possible. Electricity is indorsed as a very valuable remedy in certain 
diseases, and as an invaluable therapeutical means in nearly all forms of Nervous Disease; but 
not as a specific for every human ill, mental and physical. 

THE ANATOMY OF INVERTEBRATED ANIMALS. 

By Thomas Henry Huxley, LL. D., F. R. S. 

I vol., i2mo. Illustrated. 596 pp. Cloth, $2.50, 

" ]Mv object in writing the book has been to make it useful to those who wish to become ac- 
qmainted with the broad outlines of what is at present known of the morphology of the Inyerte- 
braia ; though I have not avoided the incidental mention of facts connected with their physiology 
and their distribution. On the other hand, I have abstained from discussing questions of etiol- 
ogy, not because I underestimate their importance, or am insensible to the interest of the great 
problem of evolution, but because, to my mind, the growing tendency to mix up etiological specu- 
lations with morphological generalizations will, if unchecked, throw biology into confusion." — 
From Preface. 



Z>. APPLETON &- CO:S MEDICAL WORKS. 



23 



HAND-BOOK OF SKIN DISEASES. By Dr. Isidor 

Neumann, Lecturer on Skin Diseases in the Royal University of Vienna. 

Translated from the German, second edition, with Notes, by Lucius D. 

BuLKLEY, A. M., M. D., Surgeon to the New York Dispensary, Department 

of Venereal and Skin Diseases ; Assistant to the Skin Clinic of the College 

of Physicians and Surgeons, New York, etc., etc. 

I vol., 8vo, 467 pp., and 66 Woodcuts. Cloth, $4; sheep, $5. 

Professor Neumann ranks sec- 
ond only to Hebra, whose assist- 
ant he was for many years, and his 
work may be considered as a fair 
exponent of the German practice 
of Dermatology. The book is 
abundantly illustrated with plates 
of the histology and pathology of 
the skin. The translator has en- 
deavored, by means of notes from 
French, English, and American 
sources, to make the work valua- 
ble to the student as well as to the 
practitioner. 



" It is a work which I shall hearti- 
ly recommend to my class of students 
at the University of Pennsylvania, /J- 
and one which I feel sure will do 
much toward enlightening the pro- 
fession on this subject." — Louis A. 
Duhring. g ' 

"There certainly is no work ex- 
tant which deals so thoroughly with 
the Pathological Anatomy of the Skin 
as does this hand-book." — New York 
Medical Record. 

"I have already twice expressed 
my favorable opinion of the book in f 
print, and am glad that it is given to 
the public at last." — James C. W/iite^ 
Boston. 

"More than two years ago we 
noticed Dr. Neumann's admirable 
work in its original shape, and we are 
therefore absolved from the necessity 
of saying more than to repeat our 
strong recommendation of it to Eng- 
lish readers. " — Practitioner. 




Lichen scrofulosorum. 



THE PATHOLOGY OF MIND. Being the third edition 

of the Second Part of the "Physiology and Pathology of Mind," recast, 
enlarged, and rewritten. By Henry Maudsley, M. D., London. 

I vol., l2mo, 580 pp. $2. 

CONTENTS.— OA'XY'i&x I. Sleeping and Dreaming; II. Hypnotism, Somnambulism, and 
Allied States ; III. The Causation and Prevention of Insanity: (A) Etiological ; IV. The same 
continued; V. The Causation and Prevention of Insanity : (B; Pathological; VI. The Insanity of 
Early Life; VII. The Symptomatology of Insanity; VIII. The same continued; IX. Clinical 
Groups of Mental Disease; X. The Morbid Anatomy of Mental Derangement ; XI. The Treat- 
ment of Mental Disorders. 

The new material includes chapters on "Dreaming," " Somn.ambulism and its Allied States," 
and large additions in the cliapters on the "Causation and Prevention of Insanity." 

"Unquestionably one of the ablest and most "Dr. Maudsley has had the courage to under- 

important works on the subject of which it treats take, and the skill to execute, what is, at least in 
that has ever appeared, and does credit to his philo- I'^nglish, an original enterprise." — London Satur- 
sophical acumen and accurate observation." — Alcdi- day Review, 
cal Record. 



24 



D. APPLETON (S- CO.'S MEDICAL WORKS. 



MEDICAL RECOLLECTIONS OF THE ARMY OF 

THE POTOMAC. By Jonathan Letterman, M. D., late Surgeon 

U. S. A., and Medical Director of the Army of the Potomac. 

I vol., 8vo, 194 pp. Cloth, $1. 

" We venture to assert that but few who open 
this volume of medical annals, pregnant as they are 



with instruction, will care to do otherwise than 
finish them at a sittinir." — Medical Record. 



RESPONSIBILITY IN MENTAL DISEASES. By 

Henry Maudsley, M. D., London. 

I vol., i2mo, 313 pp. Cloth, $1.50. 

"This book is a compact presentation of those 
facts and principles which require to be taken into 
account in estimating human responsibility — not le- 
gal responsibility merely, but responsibility for con- 
duct in the family, the school, and all phases of 



social relation, in which obligation enters as an 
element. The work is new in plan, and was writ- 
ten to supply a wide-felt want which has not hither- 
to been met." — The Popular Science Monthly. 



BODY AND MIND: An Inquiry into their Connection and 
Mutual Influence, especially in reference to Mental Disorders; an enlarged 
and revised edition, to which are added Psychological Essays. By Henry 
Maudsley, M. D., London. 

I vol., i2mo, 275 pp. Cloth, $1.50. 

The general plan of this work may be described as being to bring man, both in his physical 
and mental relations, as much as possible within the scope of scientific inquiry. 

the abundant cases compiled by the medical author- 
ities ; but the physician, on the other hand, had no 
theoretical clew to his observations beyond a smat- 
tering of dogmatic psychology learned at college. 
To effect a reconciliation between the Psychology 
and the Pathology of the mind, or rather to con- 
struct a basis for both in a common science, is the 
aim of Dr. Maudsley's book." — London Saturday 
Review. 



" Dr. Maudsley has had the courage to under- 
take, and the skill to execute, what is, at least in 
English, an original enterprise. This book is a 
manual of mental science in all its parts, embracing 
all that is known in the existing state of physiology. 
. . . Many and valuable books have been written 
by English physicians on insanity, idiocy, and all 
the forms of mental aberration. But derangement 
had always been treated as a distinct subject, and 
therefore empirically. That the phenomena of 
sound and unsound minds are not matters of dis- 
tinct investigation, but inseparable parts of one and 
the same inquiry, seems a truism as soon as stated. 
But, strange to say, they had always been pursued 
separately, and been in the hands of two distinct 
classes of investigators. The logicians and meta- 
physicians occasionally borrowed a stray fact from 



"A representative work, which every one must 
study who desires to know what is doing in the way 
of real progress, and not mere chatter, about men- 
tal physiology and pathology." — Lancet. 

" It distinctly marks a step in the progress of 
scientific psychology." — The Practitioner. 



HEALTH, AND HOW TO PROMOTE IT. By Richard 

McSherry, M. D., Professor of Practice of Medicine, University of Mary- 
land ; President of Baltimore Academy of Medicine, etc. 
I vol., l2mo, 185 pp. Cloth, $1.25. 



" An admirable production which should findjts 
way into every family in the country. It comprises 
a vast amount of the most valuable matter expressed 
in clear and terse language, and the subjects of 
which it treats are of the deepest interest to every 
human being."— /^r^/. S. D. Gross, of Jefferson 
Medical College, Philadelphia. 

" On the whole, this little book seems to us very 
well adapted to its purpose, and will, we hope, have 
a wide circulation, when it can not fail to do much 
good." — American Jourtial of Medical Sciences. 

"It is the work of an able physician, and is 
written in a style which all people can understand. 
It deals with practical topics, and its ideas are set 
forth so pointedly as to make an impression." — 
The Independent . 



" This is a racy little book of 185 pages, full of 
good advice and important suggestions, and written 
in a free and easy style, which crops out in con- 
tinued humor and crispness by which the advice is 
seasoned, and which render the reading of the book 
a pleasant pastime to all, whether professionals or 
non-professionals." — Canadiati Journal of Medical 
Science. 

" It contains a great deal of useful information, 
stated in a very simple and attractive way." — Balti- 
more Gazette. 

" This is one of the best popular essays on the 
subject we have ever seen. It is short, clear, posi- 
tive, sensible, bright and entertaining in its style, 
and is as full of practical suggestions as a nut is 
full of meat." — Literary World. 



D. APPLETON &^ CO:S MEDICAL WORKS. 



25 



THE PHYSIOLOGY OF THE MIND. Being the First 

Part of a third edition, revised, enlarged, and in a great part rewritten, of 
" The Physiology and Pathology of the Mind." By Henry Maudsley, 
M. D., London, 

I vol., l2mo, 547 pp. Cloth, $2. 

CONTENTS.— Ch2ipie:r I. On the Method of the Study of the Mind ; II. The Mind and the 
Nervous System; III. The Spinal Cord, or Tertiary Nervous Centers; or, Nervous Centers of 
Reflex Action ; IV. Secondary Nervous Centers, or Sensory Ganglia ; Sensoriuna Commune ; V. 
Hemispherical Ganglia; Cortical Cells of the Cerebral Hemispheres; Ideational Nervous Cen- 
ters; Primary Nervous Centers; Intellectorium Commune; VI. The Emotions ; VII. Volition ; 
VIII. Motor Nervous Centers, or Motorium Commune and Actuation or Effection ; IX. Memory 
and Imagination. 

instructive display of notes and quotations from 
authoritative writers upon physiology and psychol- 
ogy ; and by illustrative cases, which add materi- 
ally to the interest of the book." — Popular Science 
Monthly. 



"The ' Physiology of the Mind,' by Dr. Mauds- 
ley, is a very engaging volume to read, as it is a fresh 
and vigorous statement of the doctrines of a grow- 
ing scientific school on a subject of transcendent 
moment, and, besides many new facts and impor- 
tant views brought out in the text, is enriched by an 



PHYSICAL EDUCATION ; or, THE HEALTH LAWS 

OF NATURE. By Felix L. Oswald, M. D. 

l2mo, cloth. $1. 



"Dr. Oswald is a medical man of thorough 
preparation and large professional experience, and 
an extensively traveled student of nature and of 
men. While in charge of a military hospital at 
Vera Cruz, his own health broke down from long 
exposure in a malarial region, and he then struck 
for the Mexican mountains, where he became direct- 
or of another medical establishment. He has also 
journeyed extensively in Europe, South America, 
and the United States, and always as an open-eyed, 
absorbed observer of nature and of men. The 
' Physical Education ' is one of the most whole- 
some and valuable books that have emanated from 
the American press in many a day. Not only can 
everybody understand it, and, what is raox&,/eel it, 
but everybody that gets it will be certain to read and 
re-read it. We have known of the positive and 
most salutary influence of the papers as they ap- 
peared in the ' Monthly,' and the extensive demand 
for their publication in a separate form shows how 
they have been appreciated. Let those who are able 
and wish to do good buy it wholesale and give it to 
those less able to obtain it." — T/ie Popular Science 
Monthly. 

" Here we have an intelligent and sensible treat- 
ment of a subject of great importance, viz. , physi- 
cal education. We give the headings of some of 
the chapters, viz. : fJiet ; In-door Life ; Out-door 
Life ; Gymnastics ; Clothing ; Sleep ; Recreation ; 
Remedial Education ; Hygienic Precautions ; Pop- 
ular Fallacies. These topics are discussed in a plain, 
common-sense style suited to the popular mind. 



Books of this character can not be too widely read." 
— Albany {N. Y.) Argus. 

"Dr. Oswald is as epigrammatic as Emerson, 
as spicy as Montaigne, and as caustic as Heine. 
And yet he is a pronounced vegetarian. His first 
chapter is devoted to a consideration of the diet 
suitable for human beings and infants. In the next 
two he contrasts life in and out of doors. He then 
gives his ideas on the subjects of g^'mnastics, cloth- 
ing, sleep, and recreation. He suggests a system of 
remedial education and hygienic precautions, and 
he closes with a diatribe against popular fallacies." 
— Philadelphia Press. 

" It is a good sign that books on physical train- 
ing multiply in this age of mental straining. Dr. 
Felix L. Oswald, author of the above book, may be 
somewhat sweeping in his statements and beliefs, 
but every writer who, like him, clamors for sim- 
plicity, naturalness, and frugality in diet, for fresh 
air and copious exercise, is a benefactor. Let the 
dyspeptic and those who are always troubling them- 
selves and their friends about their manifold ail- 
ments take Dr. Oswald's advice and look more to 
their aliments and their exercise." — New York 
Herald. 

" One of the best books that can be put in the 
hands of young men and women. It is very inter- 
esting, full of facts and wise suggestions. It points 
out needed reforms, and the way we can become a 
strong and healthy people. It deserves a wide cir- 
culation." — Boston Commonwealth. 



GALVANO -THERAPEUTICS. The Physiological and 

Therapeutical Action of the Galvanic Current upon the Acoustic, Optic, 

Sympathetic, and Pneumogastric Nerves. By William B. Neftel. 

Fourth edition, i vol., i2mo, 161 pp. Cloth, $1.50. 

This book has been republished at the request of several aural surgeons and other professional 
gentlemen, and is a valuable treatise on the subjects of which it treats. Its author, formerly visit- 
ing physician to the largest hospital of St. Petersburg, has had the very best facilities for investi- 
gation. 

"This little work shows, as far as it goes, full " Those who use electricity should get this work, 

knowledge of what has been done on the subjects and those who do not should peruse it to learn that 

treated of, and the author's practical acquaintance there is one more therapeutical agent that they could 

with them." — New York Medical Journal. and should possess." — The Medical Investigator. 



26 



D. APPLETON &- CO.'S MEDICAL WORKS. 



OVARIAN TUMORS; their Pathology. Diagnosis, and Treat- 
ment, with Reference especially to Ovariotomy. By E, R. Peaslee, M. D., 
Professor of Diseases of Women in Dartmouth College ; formerly Professor 
of Obstetrics and Diseases of Women in the New York Medical College, etc. 

I vol., 8vo, 551 pp. Illustrated with many Woodcuts, and a Steel Engraving of Dr. E. McDow- 
ell, the "Father of Ovariotomy." Cloth, $5; sheep, $6. 

This valuable work, embracing the results of many years of successful experience in the de- 
partment of which it treats, will prove most acceptable to the entire profession ; while the high 
standing of the author and his knowledge of the suljject combine to make the book the best in the 
language. Fully illustrated, and abounding with information, the result of a prolonged study of 
the subject, the work should be in the hands of every physician in the country. 

" In closing our review of this work, we can not 
avoid again expressing our appreciation of the thor- 
ough study, the careful and honest statements, and 
candid spirit, which characterize it. For the use of 
the student we should give the preference to Dr. 
Peaslee' s work, not only front its cotnpleteness, but 
from its more tnethodical arrangetnent." — Ameri- 
ca?! Jotirnal of Medical Scie7ices, 



" We deem its careful perusal indispensable to 
all who would treat ovarian tumors with a good con- 
science." — Americati jfournal of Obstetrics. 

" It shows prodigal industry, and embodies with- 
in its five hundred and odd pages pretty much all 
that seems worth knowing on the subject of ovarian 
diseases." — Philadelphia Medical Times. 



A TREATISE ON DISEASES OF THE BONES. By 

Thomas M. Markoe, M. D., Professor of Surgery in the College of Physi- 
cians and Surgeons, New York, etc. With numerous Illustrations. 
I vol., 8vo, 416 pp. Cloth, $4.50. 

Specimen of Illustration. This valuable work is a trea- 

tise on Diseases of the Bones, 
embracing their structural 
changes as aifected by disease, 
their clinical history and treat- 
ment, including also an account 
of the various tumors which 
grow in or upon them. None 
of the injuries of bone are in- 
cluded in its scope, and nojoirit 
diseases, excepting where the 
condition of the bone is a prime 
factor in the problem of disease. 
As the work of an eminent sur- 
geon of large and varied experi- 
ence, it may be regarded as the best on the subject, and a valuable contribution to medical 
literature. 




DR. PEREIRA'S ELEMENTS OF MATERIA MEDICA 

AND THERAPEUTICS. Abridged and adapted for the Use of Medical 
and Pharmaceutical Practitioners and Students, and comprising all the 
Medicines of the British Pharmacopoeia, with such others as are frequently 
ordered in Prescriptions, or required by the Physician. Edited by Robert 
Bentley and Theophilus Redwood. 
New edition. Brought down to 1872. i vol., royal 8vo, 1,093 pp. Cloth, $7; sheep, $8. 



NOTES ON NURSING: What it is, and what it is not. By 

Florence Nightingale. 

I vol., i2mo, 140 pp. Cloth, 75 cents. 

These notes are meant to give hints for thought to those who have personal charge of the 
health of others. 

Every-day sanitary knowledge, or the knowledge of nursing, or, in other words, of how to put 
the constitution in such a state as that it will have no disease or that it can recover from disease, 
is recognized as the knowledge which every one ought to have — distinct from medical knowledge, 
which only a profession can have. 



D. APPLETON &- CO:S MEDICAL WORKS. 



27 



A TEXT-BOOK OF PRACTICAL MEDICINE. With 

Particular Reference to Physiology and Pathological Anatomy, By the 
late Dr. Felix von Niemeyer, Professor of Pathology and Therapeutics ; 
Director of the Medical Clinic of the University of Tubingen. Translated 
from the eighth German edition, by special permission of the author, by 
George H. Humphreys, M. D., one of the Physicians to Trinity Infirmary, 
Fellow of the New York Academy of Medicine, etc., and Charles E. 
Hackley, M. D., one of the Physicians to the New York Hospital and 
Trinity Infirmary, etc. 

Revised edition of 1880. 2 vols., 8vo, 1,628 pages. Cloth, $9; sheep, $11. 

The author undertakes, first, to give a picture of disease which shall be as life-like and faithful 
to nature as possible, instead of being a mere theoretical scheme ; secondly, so to utilize the more 
recent advances of pathological anatomy, physiology, and physiological chemistry, as to furnish a 
clearer insight into the various processes of disease. 

The work has met with the most flattering reception and deserved success ; has been adopted 
as a text-book in many of the medical colleges both in this country and in Europe ; and has re- 
ceived the very highest encomiums from the medical and secular press. 

unhesitatingly answer, ' It is ! ' " — New York Medi' 
cal yournal. 

" It is comprehensive and concise, and is char- 
acterized by clearness and originality." — Dublin 
Quarterly yournal of Medicine. 

" Its author is learned in medical literature ; he 
has arranged his materials with care and judgment, 
and has thought over them." — The Lancet. 

"While, of course, we can not undertake are- 
view of this immense work of about i ,600 pages in 
a journal of the size of ours, we may say that we 
have examined the volumes very carefully, as to 
whether to recommend them to practitioners or not ; 
and we are glad to say, after a careful review, ' Buy 
the book.' The chapters are succinctly written. 
Terse terms and, in the main, brief sentences are 
used. Personal experience is recorded, with a proj)- 
er statement of facts and observations by other au- 
thors who are to be trusted. A very excellent index 
is added to the second volume, which helps very 
much for ready reference." — Virginia Medical 
Monthly, 



" This new American edition of Niemeyer fully 
sustains the reputation of previous ones, and may 
be considered, as to style and matter, superior to 
any translation that could have been made from the 
latest German edition. It will be recollected that 
since the death of Professor Niemeyer, in 1871, his 
work has been edited by Dr. Eugene Seitz. Although 
the latter gentleman has made many additions and 
changes, he has destroyed somewhat the individual- 
ity of the original. The American editors have 
wisely resolved to preserve the style of the author, 
and adhere, as closely as possible, to his individual 
views and his particular style. Extra articles have 
been inserted on chronic alcoholism, morphia-poi- 
soning, paralysis agitans, scleroderma, elephantiasis, 
progressive pernicious anaemia, and a chapter on 
yellow fever. The work is well printed as usual." 
— Medical Record. 

"The first inquiry in this country regarding a 
German book generally is, ' Is it a work of practi- 
cal value ? ' Without stopping to consider the just- 
ness of the American idea of the ' practical,' we can 



ESSAYS ON THE FLOATING MATTER OF THE 



AIR, in Relation to Putrefaction and Infection. 
DALL, F. R. S. 

Cloth, $1.50. 



By Professor John Tyn- 



l2mo. 



CONTENTS. — I. On Dust and Disease; II. Optical Deportment of the Atmosphere in Re- 
lation to Putrefaction and Infection; III. Further Researches on the Deportment and Vitality of 
Putrefactive Organisms ; IV. Fermentation, and its Bearings on Surgery and Medicine; V. Spon- 
taneous Generation ; Appendix. 



" Professor Tyndall's book is a calm, patient, 
clear, and thorough treatment of all the questions 
and conditions of nature and society involved in 
this theme. The work is lucid and convincing, yet 
not prolix or pedantic, but popular and really en- 
joyable. It is worthy of patient and renewed 
study. " — Philadelphia Times. 

" The matter contained in this work is not only 
presented in a very interesting way, but is of great 
value." — Boston yourjial 0/ Commerce. 

"The germ theory of disease is most intelH- 
gently presented, and indeed the whole work is 
instinct with a high intellect." — Boston Common- 
luealth. 



" In the book before us we have the minute de- 
tails of hundreds of observations on infusions ex- 
posed to optically pure air ; infusions of mutton, 
beef, haddock, hay, turnip, liver, hare, rabbit, 
grouse, pheasant, salmon, cod, etc. ; infusions 
heated by boiling water and by boiling oil, some- 
times for a few moments and sometimes for several 
hours, and, however varied the mode of procedure, 
the result was invariably the same, with not even a 
shade of uncertainty. The fallacy of spontaneous 
generation and the probability of the germ theoiy 
of disease seem to us the inference, and the only 
inference, that can be drawn from the results of 
nearly ten thnusanri experiments performed by Pro- 
fessor Tyndall within the last two years.j' — Pitts- 
burg Telegraph. 



28 



D. APPLE TON &^ CO:S MEDICAL WORKS. 



THE APPLIED ANATOMY OF THE NERVOUS 

SYSTEM, being a Study of this Portion of the Human Body from a Stand- 
point of its General Interest and Practical Utility, designed for Use as a 
Text-book and as a Work of Reference, By Ambrose L. Ranney, A. M., 
M. D., Adjunct Professor of Anatomy and late Lecturer on the Diseases of 
the Genito-Urinary Organs and on Minor Surgery in the Medical Depart- 
ment of the University of the City of New York, etc., etc. 

I vol., 8vo. Profusely illustrated. Cloth, $4; sheep, $5. 




Distribution of the Hypo-glossal Nerve. 



" This is a useful book, and one of novel de- 
sign. It is especially valuable as bringing together 
facts and inferences which aid greatly in forming 
correct diagnoses in nervous diseases." — Boston 
Medical and Surgical Journal. 

" This is an excellent work, timely, practical, 
and well executed. It is safe to say that, besides 
Hammond's work, no book relating to the nervous 
system has hitherto been published in this country 
equal to the present volume, and nothing superior 
to it is accessible to the American practitioner." — 
Medical Herald. 

" There are many books, to be sure, which con- 
tain here and there hints in this field of great value 
to the physician, but it is Dr. Ranney's merit to 
have collected these scattered items of interest, and 
to have woven them into an harmonious whole, 
thereby producing a work of wide scope and of cor- 
respondingly wide usefulness to the practicing physi- 
cian. 

'"The book, it will be perceived, is of an emi- 
nently practical character, and, as such, is addressed 
to those who can not afford the time for the perusal 
of the larger text-books, and who must read as they 
run." — New York Medical yottrnal. 



" Professors of anatomy in schools and colleges 
can not afford to be without it. We recommend 
the book to practitioners and students as well. " — 
Virginia Medical Monthly. 

" It is an admitted fact that the subject treated 
of in this work is one sufficiently obscure to the pro- 
fession generally to make any work tending to elu- 
cidation most welcome. 

" We earnestly recommend this work as one un- 
usually worthy of study." — Buffalo Medical and 
Surgical Journal. 

"Dr. Ranney has firmly grasped the essential 
features of the results of the latest study of the 
nervous system. His work will do much toward 
popularizing this study in the profession. 

" We are sure that all our readers will be quite 
as much pleased as ourselves by its careful study." 
— Detroit Lancet. 

"A useful and attractive book, suited to the 
time." — Louisville Medical News. 

' ' Our impressions of this work are highly fa- 
vorable as regards its practical value to students, as 
well as to educated medical men." — Pacific Medical 
and Surgical Journal. 



D. APPLETON <&- CO:S MEDICAL WORKS. 



29 



' ' The work shows great care in 
its preparation. We predict for it a 
large sale among the more progres- 
sive practitioners." — Michigan Medi- 
cal News. 

" We are acquainted with no re- i\ 
cent work which deals with the sub- 
ject so thoroughly as this ; hence, it ^^ 
should commend itself to a large class ^ 
of persons, not merely specialists, but ^ 
those who aspire to keep posted in 
all important advances in the science 
and art of medicine." — Alaryland 
Medical Jour7ial. 

' ' This work was originally ad- 
dressed to medical under-graduates, 
but it will be equally interesting and 
valuable to medical practitioners who 
still acknowledge themselves to be 
students. It is to be hoped that their 
number is not small." — New Orlea7ts 
Medical and Surgical yourtial. 

" We think the author has cor- 
rectly estimated the necessity for such 
a volume, and we congratulate him 
upon the manner in which he has 
e.xecuted his task. 

" As a companion volume to the 
recent works on the diseases of the 
nervous system, it is issued in good 
time." — North Carolina Medical 
yournal. 

' ' A close and careful study of this 
work, we feel convinced, will impart 
to the student a large amount of practical knowledge which could not 
be gained elsewhere, except by wading through the enormous quan- 
tity of neurological literature which has appeared during past years, 
a task which few would have either time or inclination to accomplish. 
Here it will all be found condensed, simplified, and systematically 
arranged. The nature of the work is so fully explained in its title 
that little or nothing on that point need be said here. We will, how- 
ever, say that the whole subject is treated in a lucid manner, and that, 
so far as we are able to judge, nothing seems left out which could in 
any way improve or add to the value of the book." — Medical arid 
Surgical Reporter (^Philadelphia). 

" Dr. Ranney has done a most useful and praiseworthy task in 
that he will have saved many of the profession from the choice of 
going through the research we have indicated, or remaining in igno- 
rance of many things most essential to a sound medical knowledge." — Medical Record. 

"We are sure that this book will be well received, and will prove itself a very useful companion both 
for regular students of anatomy and physiology, and also for practitioners who wish to work up the diag- 
nosis of cases of disorder of the nervous system." — Canada Medical and Surgical your?ial. 

" Dr. Ranney has done his work well, and given accurate information in a simple, readable style." — 
Philadelphia Medical Times. 




Thi Deep Branch of the External 
Plantar Nerve. 




The Small Sciatic Nerve, with its 
Branches of Distribution and 
Termination. 



A MINISTRY OF HEALTH AND OTHER AD- 
DRESSES. By Dr. B. W. Richardson, M. D., M. A., F. R. S., etc., etc. 

I vol., i2mo, 354 pp. Cloth, $1.50. 



"The author is so widely and favorably known 
that any book which bears his name will receive re- 
spectful attention. He is one of those highly edu- 
cated yet practical, public-spirited gentlemen who 
adorn the profession of medicine and do far more 
than their share toward elevating its position before 
the public. This bonk, owing to the character of 
the matter considered and the author's attractive 
style, affords means for relaxation and instruction 
to everv thoughtful person." — Medical Gazette. 

" This book is made up of a number of addresses 
on sanitary subjects, which Dr. Richardson deliv- 
ered at various times in Great Britain, and which 
are intended to invite attention to the pressing re- 
forms that are making progress in medical science. 
The work, which has the great merit of being writ- 



ten in the simplest and clearest language, gives 
special attention to the origin and causes of diseases, 
and a demonstration of the physical laws by which 
they may be prevented. . . . 

" The author does not, like some members of his 
profession, enter into a learned description of cures, 
but traces the causes of diseases with philosophical 
precision. The book contains what every one should 
know, and members of the medical profession will 
not find a study of it in vain." — Philadelphia En- 
quirer. 

" The wide study of these lectures by both the 
profession and the laity would greatly advance the 
interests of both by stimulating thought and action 
respecting the most vital subjects that can engage 
the human mind." — Detroit Lancet. 



30 D. APPLETON &- CO.'S MEDICAL WORKS. 

DISEASES OF MODERN LIFE. By Dr. B. W. Richard- 
son, M. D., M. A., F. R. S., etc., etc. 

I vol., i2mo, 520 pp. Cloth, $2. 

"In this valuable and deeply interesting work of atmospheric temperature, of atmospheric press- 

Dr. Richardson treats the nervous system as the ure, of moisture, winds, and atmospheric chemical 

very pnnciple of life, and he shows how men do it changes, which are of great general interest "—Na- 

violence, yet expect immunity where the natural sen- tu?-e. 00 . « 

tence is death."— C//ar/i?j/'^« Courier. ur> »• 1 .* ^• 

.,_, , • r . . . Particular attention is given to diseases from 

u,^ ''y^' '^ ^^""^^^^^'"^ ^^ ^ P""^*^'"^^^ g^'*^^ worry and mental strain, from the passions from 

to enable the reader to detect and avoid various alcohol, tobacco, narcotics, food, impure air late 

sources of^ disease and it contains, in addition, sev- hours, and broken sleep, idleness, intermarriaee 

*^ , j'^'/u u^°1'^ ''P^''''^ on natural life and natu- etc., thus touching upon causes which do not enter 

ral death, the phenomena of disease, disease ante- into the consideration of sickness."— ^oj/^« Com- 

cedent to birth, and on the effects of the seasons, moniveaU/i. 

THE WATERING-PLACES AND MINERAL SPRINGS 

OF GERMANY, AUSTRIA, AND SWITZERLAND. With Notes on 

Climatic Resorts and Consumption, Sanitariums, Peat, Mud, and Sand 

Baths, Whey and Grape Cures, etc. By Edward Gutmann, M. D 

With Illustrations, Comparative Tables, and a Colored Map, explaining the Situation and Chemi- 
cal Composition of the Spas, i vol., i2mo. Cloth, $2.50. 

"Dr. Gutmann has compiled an excellent medi- tions, with the therapeutical applications of the 

cal guide, which gives full information on the man- mineral waters, are very thoroughly presented in 

ners and customs of living at all the principal separate parts of the volume."— A ^w J ■^;-yt 7/>«^i' 
watering-places in Europe. The chemical composi- 

A PRACTICAL MANUAL ON THE TREATMENT 

OF CLUB-FOOT. By Lewis A. Sayre, M. D., Professor of Orthopedic 
Surgery and Clinical Surgery in Bellevue Hospital Medical College; Con- 
sulting Surgeon to Bellevue Hospital, Charity Hospital, etc., etc. 
Fourth edition, enlarged and corrected, i vol., i2mo. Illustrated. Cloth, $1.25. 

" A more extensive experience in the treatment of club-foot has proved that the doctrines taught 
in my first edition were correct, viz., that in all cases of congenital club-foot the treatment should 
commence at birth, as at that time there is generally no difficulty that can not be overcome by the 
ordinary family physician; and that, by following the simple rules laid down in this volume, the 
great majority of cases can be relieved, and many cured, without any operation or surgical inter- 
ference. If this early treatment has been neglected, and the deformity has been permitted to in- 
crease by use of the foot in its abnormal position, surgical aid may be requisite to overcome the 
difficulty ; and I have here endeavored to clearly lay down the rules that should govern the treat- 
ment of this class of cases." — Preface. 

"The book will very well satisfy the wants of use, as stated, it is intended."— AVzy York Medical 
the majority of general practitioners, for whose Journal. 

COMPENDIUM OF CHILDREN'S DISEASES. A 

Hand-Book for Practitioners and Students. By Dr. Johann Steiner, 
Professor of the Diseases of Children in the University of Prague. Trans- 
lated from the second German edition by Lawson Tait, F. R. C. S., Sur- 
geon to the Birmingham Hospital for Women. 

I vol., 8vo. Cloth, $3.50; sheep, $4.50. 

" Dr. Steiner's book has met with such marked success in Germany that a second edition has 
already appeared, a circumstance v.'hich has delayed the appearance of its English form, in order 
that I might be able to give his additions and corrections. 

" I have added as an Appendix the ' Rules for Management of Infants,' which have been issued 
by the staff of the Birmingham Sick Children's Hospital, because I think that they have set an ex- 
ample, by freely distributing these rules among the poor, for which they can not be sufficiently 
commended, and which it would be wise for other sick children's hospitals to follow. 

" I have also added a few notes, chiefly, of course, relating to the surgical ailments of chil- 
dren." — Extract from Translator's Freface. 



D. APPLETON &- CO.'S MEDICAL WORKS. 



31 



HEALTH : A Hand-Book for Households and Schools. By 

Edward Smith, M. D., F. R. S., Fellow of the Royal College of Physicians 

and Surgeons of England, etc. 

I vol., i2mo. Illustrated. 198 pp. Cloth, $1. 

It is intended to inform the mind on the subjects involved in the word Health, to show how 
health may be retained and ill-health avoided, and to add to the pleasure and usefulness of life. 

"The author of this manual has rendered a real 
service to families and teachers. It is not a mere 
treatise on health, sach as would be written by a 
medical professor for medical students. Nor is it 
a treatise on the treatment of disease, but a plain, 
common-sense essay on the prevention of most of 
the ills that flesh is heir to. There is no doubt that 
much of the sickness with which humanity is af- 
flicted is the result of ignorance, and proceeds from 



the use of improper food, from defective drainage, 
overcrowded rooms, ill-ventilated workshops, im- 
pure water, and other like preventable causes. 
Legislation and municipal regulations may do 
something in the line of prevention, but the people 
themselves can do a great deal more — particularly 
if properly enlightened ; and this is the purpose of 
the book." — Albany Journal. 



LECTURES ON ORTHOPEDIC SURGERY AND DIS- 
EASES OF THE JOINTS. By Lewis A. Sayre, M. D., Professor of 
Orthopedic Surgery and Clinical Surgery in Bellevue Hospital Medical Col- 
lege ; Consulting Surgeon to Bellevue Hospital, Charity Hospital, etc., etc. 

Second edition, revised and greatly enlarged, with 324 Illustrations, i vol., 8vo, 569 pp. Cloth, 

$5 ; sheep, $6, 

This edition has been thoroughly revised and rearranged, and the stibjects classified in the ana- 
tomical and pathological order of their development. Many of the chapters have been entirely 
rewritten, and several new ones added, and the whole work brought up to the present time, with 
all the new improvements that have been developed in this department of surgery. Many new 
engravings have been added, each illustrating some special point in practice. 

Specimen of Illustration. 




"The name of the author is a sufficient guar- 
antee of its excellence, as no man in America or 
elsewhere has devoted such unremitting attention 
for the past thirty years to this department of Sur- 
gery, or given to the profession so many new truths 
and laws as applying to the pathology and treat- 
ment of deformities." — ll'esler?i Lancet. 

" The name of Lewis A. Sayre is so intimately 
connected and identified with orthopedics in all its 
branches, that a book relating his experience can 
not but form an epoch in medical science, and prove 
a blessing to the profession and humanity. Dr. 
Sayre's views on many points differ from those 
entertained by other surgeons, but the great suc- 
cesses he has obtained fully warrant him in main- 
taining the 'courage of his opinions.' " — .linerican 
Journal 0/ Obstetrics. 



"Dr. Sayre has stamped his individuality on 
every part of his book. Possessed of a taste for 
mechanics, he has admirably utilized it in so modi- 
fying the inventions of others as to make them of 
far greater practical value. The care, patience, and 
perseverance which he exhibit-; in fulfilling all the 
conditions necessary for succr-ss in the treatment of 
this troublesome class of cases are worthy of all 
praise and imitation." — Detroit Reviev) 0/ Medi- 
cine. 

"Its teaching is sound, and the originality 
throughout very pleasing ; in a word, no man 
should attempt the treatment of deformities of joint 
affections without being familiar with the views 
Cf)ntained in these lectures." — Canada Medical and 
Surgical Journal. 



32 



D. APPLE TON &- CO:S MEDICAL WORKS. 



LECTURES UPON DISEASES OF THE RECTUM 

AND THE SURGERY OF THE LOWER BOWEL. Delivered at 
the Bellevue Hospital Medical College by W. H. Van Buren, M. D., late 
Professor of the Principles and Practice of Surgery in the Bellevue Hospi- 
tal Medical College, etc., etc. 

Second edition, revised and enlarged i volume 8vo, 412 pp., with 27 Illustrations and complete 

Index. Cloth, $3 ; sheep, $4. ^ 

Specimen of Illustration. "The reviewer too often finds it a difficult 

task to discover points to praise, in order that 
his criticisms may not seem one-sided and un- 
just. These lectures, however, place him upon 
the other horn of the dilemma, viz., to find 
somewhat to criticise severely enough to clear 
himself of the charge of indiscriminating lau- 
dation. Of course, the author upholds some 
views which conflict with other authorities, but 
he substantiates them by the most powerful of 
argurnents, viz., a large experience, the results 
of which are enunciated by one who elsewhere 
shows that he can appreciate, and accord the 
due value to, the work and experience of 
oi\\eTS."—Arc/iwes of Medicine. 

" The present is a new volume rather than 
a new edition. Both its size and material 
are vastly beyond its predecessor. The same 
scholarly method, the same calm, convincing 
statement, the same wise, carefully matured 
counsel, pervade every paragraph. The dis- 
comfort and dangers of the diseases of the 
rectum call for greater consideration than 
tliey usually receive at the hands of the pro- 
fession." — Detroit Lancet. 

" These lectures are twelve in number, and 
may be taken as an excellent epitome of our 
present knowledge of the diseases of the parts 
in question. The work is full of practical 
matter, but it owes not a little of its value to 
the original thought, labor, and suggestions 
as to the treatment of disease, which always 
characterize the productions of the pen of Dr. 
Van ^m&T\."— Philadelphia Medical Times. 
"The most attractive feature of the work 
„_ 1, u- » • J rr^, ^^ ^^^ plain, common-sense manner in which 

each subject is treated. The author has laid down instructions for the treatment, medicinal and opera- 
tive, of rectal diseases in so clear and lucid style as that any practitioner is enabled to follow it The 
large and successful experience of the distinguished author in this class of diseases is sufficient of itself to 
warrant the high character of the book. "—Nashville yournal of Medicine a?id Surgery. 

We have thus briefly tried to give the known to the profession as one of our most accom- 




reader an idea of the scope of this work : and the 
work is a good one— as good as either Allingham's 
or Curling's, with which it will inevitably be com- 
pared. Indeed, we should have been greatly sur- 
prised if any work from the pen of Dr. Van Buren 
had not been a good one ; and we have to thank 
him that for the first time we have an American 
text-book on this subject which equals those that 
have so long been the standards."— iV^w York Med- 
ical fournal. 

" Mere praise of a book like this would be super- 
fluous—almost impertinent. The author is well 



phshed surgeons and ablest scientific men. Much 
is expected of him in a book like the one before us, 
and those who read it will not be disappointed. It 
will, indeed, be widely read, and, in a short time, 
take its place as the standard American authority. " 
— St. Louis Courier of Medicine. 

" Taken as a whole, the book is one of the most 
complete and reliable ones extant. It is certainly 
the best of any similar work from an American au- 
thor. It is handsomely bound and illustrated, and 
should be in the hands of every practitioner and 
student of medicine. " — Louisville Medical Herald. 



REPORTS. Bellevue and Charity Hospital Reports for 1870, 
containing valuable contributions from Isaac E. Taylor, M. D., Austin 
Flint, M. D., Lewis A. Savre, M. D., William A. Hammond, M. D., T. 
Gaillard Thomas, M. D., Frank H. Hamilton, M. D., and others. 

I vol., 8vo, 415 pp. Cloth, $4. 
" These institutions are the most important, as connected with them are acknowledged to be among 
regards accommodations for patients and variety of the first in their profession, and the volume is an 
ases treated, of any on this continent, and are sur- important addition to the professional hterature of 
passed by but few in the world. The gentlemen Xhis coMnXxy."— Psychological Journal 



D. APPLETON <S- CO.'S MEDICAL WORKS. 23 

THE POSTHUMOUS WORKS OF SIR JAMES YOUNG 

SIMPSON, Bart., M. D. In Three Volumes. 

Volume I. — Selected Obstetrical and Gynecological Works of Sir 

James Y. Simpson. Edited by J. Watt Black, M. D. 

I vol., 8vo, 852 pp. Cloth, $3; sheep, $4. 

This first volume contains many of the papers reprinted from his Obstetric Memoirs and Con- 
tributions, and also his Lecture Notes, now published for the first time, containing the substance 
of the practical part of his course of midwifery. It is a volume of great interest to the profession, 
and a fitting memorial of its renowned and talented author. 

Volume II. — Anesthesia, Hospitalism, etc. Edited by Sir Walter Simp- 
son, Bart. 

"We say of this, as of the first volume, that it may be picked out and studied with pleasure and 
should find a place on the table of every practi- profit." — The Lancet (Londoii). 
tioner ; for, although it is patchwork, each piece 

I vol., Svo, 560 pp. Cloth, $3 ; sheep, $4. 

Volume III. — Diseases of Women, Edited by Alexander Simpson, M. D. 

I vol., 8vo, 789 pp. Cloth, $3 ; sheep, $4. 
One of the best works on the subject extant. Of inestimable value to every physician. 

ON FOODS. By Edward Smith, M. D., LL. B., F. R. S., 

Fellow of the Royal College of Physicians of London, etc., etc. 

I vol., i2mo, 485 pp. Cloth, $1.75. 

" Since the issue of the author's work on ' Prac- " The book contains a series of diagrams, dis- 

tical Dietary,' he has felt the want of another, which playing the effects of sleep and meals on pulsation 

would embrace all the generally known and some and respiration, and of various kinds of food on 

less known foods, and contain the latest scientific respiration, which, as the results of Dr. Smith's own 

knowledge respecting them. The present volume is experiments, possess a very high value. We have 

intended to meet this want, and will be found use- not far to go in this work for occasions of favorable 

ful for reference, to both scientific and general criticism ; they occur throughout, but are perhaps 

readers. The author extends the ordinary view of most apparent in those parts of the subject with 

foods, and includes water and air, since they are which Dr. Smith's name is especially linked." — 

important both in their food and sanitary aspects. Lo?idon Examiner. 

A HAND-BOOK OF CHEMICAL TECHNOLOGY. 

By Rudolph Wagner, Ph, D., Professor of Chemical Technology at the 
University of Wurtzburg. Translated and edited, from the eighth German 
edition, with Extensive Additions, by William Crooks, F, R. S, 
With 336 Illustrations. I vol., 8vo, 761 pp. Cloth, $5. 

Under the head of Metallurgic Chemistry, the latest methods of preparing iron, cobalt, nickel, 
copper, copper-salts, lead and tin and their salts, bismuth, zinc, zinc-salts, cadmium, antimony, 
arsenic, mercury, platinum, silver, gold, manganates, aluminum, and magnesium, are described. 
The various applications of the voltaic current to electro-metallurgy follow under this division. 
The preparation of potash and soda-salts, the manufacture of sulphuric acid, and the recovery of 
sulphur from soda waste, of course occupy prominent places in the consideration of chemical manu- 
factures. It is difficult to overestimate the mercantile value of Mond's process, as well as the 
many new and important applications of bisulphide of carbon. The manufacture of soap will be 
found to include much detail. The technology of glass, stone-ware, limes, and mortars will pre- 
sent much of interest to the builder and engineer. The technology of vegetable fibers has been 
considered to include the preparation of flax, hemp, cotton, as well as paper-making; while the 
application of vegetable products will be found to include sugar-boiling, wine- and beer-brewing, 
the distillation of spirits, the baking of bread, the preparation of vinegar, the preservation of wood, 
etc. 

Dr. Wagner gives much information in reference to the production of potash from sugar-resi- 
dues. The use of baryta-salts is also fully described, as well as the preparation of sugar from 
beet-roots. Tanning, the preservation of meat, milk, etc., the preparation of phosphorus and ani- 
mal charcoal, are considered as belonging to the technology of animal products. The preparation 
of materials for dyeing has necessarily required much sjiace ; while the final sections of the book 
have been devoted to the technology of heating and illumination. 



34 



D. APPLE TON &^ CO.'S MEDICAL WORKS. 



A PRACTICAL TREATISE ON THE SURGICAL 

DISEASES OF THE GENITO-URINARY ORGANS, including 
Syphilis. Designed as a Manual for Students and Practitioners. With 
Engravings and Cases. By W. H, Van Buren, A. M., M. D., late Profess- 
or of Principles of Surgery, with Diseases of the Genito-Urinary System 
and Clinical Surgery, in Bellevue Hospital Medical College, etc., and E. L. 
Keyes, a. M., M. D., Professor of Dermatology in Bellevue Hospital Medi- 
cal College; Surgeon to the Charity Hospital, Venereal Diseases, etc. 
I vol., 8vo, 672 pp. Cloth, $5; sheep, $6. 

it deals. These facts are largely drawn from 
the extensive and varied experience of the au- 
thors. 

Many important branches of genito-urinary 
diseases, as the cutaneous maladies of the penis 
and scrotum, receive a thorough and exhaustive 
treatment that the professional reader will search 
for elsewhere in vain. 

The subject of syphilis is included, of neces- 
sity, in this treatise. Although properly be- 
longing to the department of Principles of Sur- 
gery, there is no disease falling within the limits 
of this work concerning which clear and correct 
ideas as to nature and treatment will, at the 
present time, so seriously influence success in 
practice. 

The work is elegantly and profusely illus- 
trated, and enriched by fifty-five original cases, 
setting forth obscure and difficult points in diag- 
nosis and treatment. 

"The authors 'appear to have succeeded admi- 
rably in giving to the world an exhaustive and re- 
liable treatise on this important class of diseases.' " 
— Northwestern Medical and Surgical Journal. 

" It is a most complete digest of what has long 
been known, and of what has been more recently 
discovered, in the field of syphihtic and genito-urin- 
ary disorders. It is, perhaps, not all exaggeration 
to say that no single work upon the same subject 
has yet appeared, in this or any foreign language, 
which is superior to it.'" — Chicago Medical Exa7n- 
iner. 

'• The commanding reputation of Dr. Van Buren 
in this specialty, and of the great school and hos- 
pital from which he has drawn his clinical materials, 
together with the general interest which attaches to 
the subject-matter itself, will, we trust, lead very 
many of those for whom it is our office to cater, to 
possess themselves at once of the volume and form 
their own opinions of its merit." — Atlanta Medical 
aftd Surgical Journal. 




Showino: Enlarged Prostate with "Third Lobe," through 
the Base of which a False Passage has been made. 

This work is really a compendium of, and a 
book of reference to, all modern works treating 
in any way of the surgical diseases of the genito- 
urinary organs. At the same time, no other 
single book contains so large an array o{ origifiol 
facts concerning the class of diseases with which 



A MANUAL OF MIDWIFERY. Including the Pathology 

of Pregnancy and the Puerperal State. By Dr. Carl Schroeder, Professor 
of Midwifery and Director of the Lying-in Institution in the University of 
Erlangen. Translated from the third German edition by Charles H. 
Carter, B. A., M. D., B. S., London, Member of the Royal College of 
Physicians, London. 
With Twenty-six Engravings on Wood, i vol., 8vo, 388 pp. Cloth, $3.50; sheep, $4.50. 
" The translator feels that no apology is needed in offering to the profession a translation of 
Schroeder's ' Manual of Midwifery.' The work is well known in Germany, and extensively used 
as a text-book ; it has already reached a third edition within the short space of two years, and it 
is hoped that the present translation will meet the want, long felt in this country, of a manual of 
midwifery embracing the latest scientific researches on the subject." 



D. APPLETON (S- CO.'S MEDICAL WORKS. 



35 



HOvSPITALS : Their History, Organization, and Construction. 
Boylston Prize-Essay of Harvard University for 1876. By W. Gill Wylie, 
M. D. I vol., 8vo, 240 pp. Cloth, $2.50, 



A TREATISE ON CHEMISTRY. By H. R. Roscoe, 

F. R. S., and C. Schorlemmer, F. R. S., Professors of Chemistry in the 
Victoria University, Owens College, Manchester. Illustrated. 

INORGANIC CHEMISTRY. 8vo. Vol. I : Non-Metallic Elements. $5. 
Vol. II, Part I : Metals. $3. Vol. II, Part II : Metals. $3. 

ORGANIC CHEMISTRY. Svo. Vol. Ill, Part I : The Chemistry of the 
Hydrocarbons and their Derivatives. $5. Vol. Ill, Part II, com- 
pleting the work : The Chemistry of the Hydrocarbons and their 
Derivatives. $5. 

" It has been the aim of the authors, in writing their present treatise, to place before the read- 
er a fairly complete and yet a clear and succinct statement of the facts of Modern Chemistry, while 
at the same time entering so far into a discussion of chemical theory as the size of the work and the 
present transition state of the science will permit. 

" Special attention has been paid to the accurate description of the more important processes 
in technical chemistry, and to the careful representation of the most approved forms of apparatus 
employed. 

" Much attention has likewise been given to the representation of apparatus adopted for lec- 
ture-room experiment, and the numerous new illustrations required for this purpose have all been 
taken from photographs of apparatus actually in use." — Extract from Preface. 

Specimen of Illustration. 
it 




" The authors are evidently bent on making; 
their book the finest systematic treatise on modern 
chemistry in the English lang^uage, an aim in which 
they are well seconded by their publishers, who 
spare neither pains nor cost in illustrating- and 
otherwise setting forth the work of these distin- 
guished chemists." — London Atltcnceum. 

" It is difficult to praise too highly the selection 
of materials and their arrangement, or the wealth 
of illustrations which explain and adorn the text. 
In its woodcuts, in its technological details, in its 
historical notices, in its references to original 
memoirs, and, it may be added, in its clear type, 
smooth paper, and ample margins, the volume un- 
der review presents most commendable features. 
Whatever tests of accuracy as to figures and facts 
we have been able to apply have been satisfactorily 



met, while in clearness of statement this volume 
leaves nothing to be desired. Moreover, it is most 
satisfactory to find that the progress of this valuable 
work toward completion is so rapid that its begin- 
ning will not have become antiquated before its end 
has been reached — no uncommon occurrence with 
elaborate treatises on natural science subjects." — 
London Academy. 

" We have no hesitation in saying that this vol- 
ume fully keeps up the reputation gained by those 
that preceded it. There is the same masterly hand- 
ling of the subject-matter ; the same diligent care 
has been bestowetl on hunting up all the old history 
connected with each product. It is this that lends 
so great a charm to the whole work, and makes it 
very much more than a mere text-book." — Satur- 
day Review. 



36 



D. APPLETON &^ CO.'S MEDICAL WORKS. 



THE BRAIN AND ITS FUNCTIONS. By J. Luys, 

Physician to the Hospice de la Salpetriere. 

With Illustrations. i2mo. Cloth, $1.50. 

' ' No living physiologist is better entitled to are the chapters dealing with the genesis and evolu- 
speak with authority upon the structure and func- tion of memory, the development of automatic ac- 
tions of the brain than Dr. Luys. His studies on ti\-ity, and the development of the notion of person- 
the anatomy of the ner\-ous system are acknowl- ality." — Boston Evetimg Traveller. 
edged to be the fullest and most systematic ever un- 
dertaken."— i"/*. James's Gazette. << Y)x. Luys, at the head of the great French In- 

" It is not too much to say that M. Luys has gone sane Asylum, is one of the most eminent and sue- 
further than any other investigator into this great cessful investigators of cerebral science now li\ing ; 
field of study, and only those who are at least dimly and he has given unquestionably the clearest and 
aware of the vast changes going on in the realm of most interesting brief account yet made of the 
psychology can appreciate the importance of his structure and operations of the brain." — Popular 
revelations. Particularly interesting and valuable Science Monthly. ' 

GENERAL PHYSIOLOGY OF MUSCLES AND 

NERVES. By Dr. I. Rosenthal, Professor of Physiology at the Univer- 
sity of Erlangen. 

With 75 Woodcuts. l2mo. Cloth, $1.50. 

" Dr. Rosenthal claims that the present work is recondite as to be unprofitable or uninteresting to 

the ' first attempt at a connected account of general the inquiring general reader." — A'ew York Ob- 

physiology of muscles and nerves.' This being the server. 

case. Dr. Rosenthal is entitled to the greatest credit i' in this volume an attempt is made to give a 

for his clear and accurate presentation of the ex- connected account of the general physiology of 

perimental data upon which must rest all future muscles and nerves, a subject which has never be- 

knowledge of a verj' important branch of medical fore had so thorough an exposition in any text- 

and electrical science. The book consists of 317 book, although it is one which has many points of 

pages, with seventy-five woodcuts, many of which interest for every cultivated man who seeks to be 

represent physiological apparatus devised by the ^y^\\ informed on all branches of the science of hfe. 

author or by his friends. Professor Du Bois-Rey- This work sets before its readers all, even the most 

mond and Helmholtz. It must be regarded as in- intricate, phases of its subject with such clearness of 

dispensable to all future courses of medical study." expression that any educated person though not a 

— Nev) York Herald. specialist can comprehend it." — New Haven Palla- 

" Although this work is written for the instruc- diutn. 
tion of students, it is by no means so technical and 

MEDICAL AND SURGICAL ASPECTS OF IN-KNEE 

(Genu-Valgura) : Its Relation to Rickets; its Prevention; and its Treat- 
ment, with or without Surgical Operation. By W. J. Little, M. D., F. R. 
C. P., late Senior Physician to and Lecturer on Medicine at the London 
Hospital; Visiting Physician to the Infant Orphan Asylum at Wanstead ; 
the Earlswood Asylum for Idiots ; Founder of the Royal Orthopsedic Hos- 
pital, etc. Assisted by E. Muirhead Little, M. R. C. S. 

One 8vo vol., containing 161 pages, with complete Index, and illustrated by upward of 50 Figures 

and Diagrams. Cloth, $2. 

A DICTIONARY OF MEDICINE, including General 

Pathology, General Therapeutics, Hygiene, and the Diseases peculiar to 

Women and Children. By Various Writers. Edited by Richard Quain, 

M. D., F. R. S., Fellow of the Royal College of Physicians; Member of the 

Senate of the University of London ; Member of the General Council of 

Medical Education and Registration; Consulting Physician to the Hospital 

for Consumption and Diseases of the Chest at Brompton, etc. 

In one large Svo volume of 1,834 pages, and 138 Illustrations. Half morocco, $8. Sold only by 

subscription. 

This work is primarily a Dictionary of Medicine, in which the several diseases are fully dis- 
cussed in alphabetical order. The description of each includes an account of its etiology and ana- 
tomical characters; its symptoms, course, duration, and termination; its diagnosis, prognosis. 



D. APPLETON &^ CO:S MEDICAL WORKS. 



Z1 



and, lastly, its treatment. General Pathology comprehends articles on the origin, characters, and 
nature of disease. 

General Therapeutics includes articles on the several classes of remedies, their modes of ac- 
tion, and on the methods of their use. The articles devoted to the subject of Hygiene treat of the 
causes and prevention of disease, of the agencies and laws affecting public health, of the means of 
preserving the health of the individual, of the construction and management? of hospitals, and of 
the nursing of the sick. 

Lastly, the diseases peculiar to women and children are discussed under their respective head- 
ings, both in aggregate and in detail. 

Among the leading contributors, whose names at once strike the reader as affording a guaran- 
tee of the value of their contributions, are the following : 



Allbutt, T. Clifford, M. A., M. D. 

Barnes, Robert, M. D. 

Bastian, H. Charlton, M. A., M. D. 

BiNZ, Carl, M. D. 

Bristovve, J. Syer, M. D. 

Brown-Sequard, C. E., M. D., LL. D. 

Brunton, T. Lauder, M. D., D. Sc. 

Fayrer, Sir Joseph, K. C. S. I., M. D., LL. D 

Fox, Tilbury, M. D. 

Galton, Captain Douglas, R. E. (retired). 

GowERS, W. R., M. D. 

Wells 



Greenfield, W. S., M. D. 

Jenner, Sir William, Bart., K. C. B., M. D. 

LeGG, J. WiCKHAM, M. D. 

Nightingale, Florence. 
Paget, Sir James, Bart. 
Parkes, Edmund A., M. D. 
Pavy, F. W., M.D. 
Playfair, W. S., M.D. 
Simon, John, C. B., D. C. L. 
Thompson, Sir Henry. 
Waters, A. T. H., M. D. 
T. Spencer. 



" Not only is the work a Dictionary of Medicine 
in its fullest sense ; but it is so encyclopedic in its 
scope that it may be considered a condensed review 
of the entire field of practical medicine. Each sub- 
ject is marked up to date and contains in a nutshell 
the accumulated experience of the leading medical 
men of the day. As a volume for ready reference 
and careful study, it will be found of immense value 
to the general practitioner and student." — Medical 
Record. 

"The 'Medical Dictionary' of Dr. Quain is 
something more than its title would at first indicate. 
It might with equal propriety be called an encyclo- 
paedia. The different diseases are fully discussed in 
alphabetical order. The description of each in- 
cludes an account of its various attributes, often 
covering several pages. Although we have pos- 
sessed the book only the short time since its publica- 
tion, its loss would leave a void we would not know 
how to fill." — Boston Medical and Surg. Journal. 

"Although a volume of over i,8oo pages, it is 
truly a multunt in parvo, and will be found of 
much more practical utility than other works which 
might be named extending over many volumes. 
The profession of this country are under obligations 
to you for the republication of the work, and I de- 
sire to congratulate you on the excellence of the 
illustrations, together with the excellent typograph- 
ical execution in all respects." — Austin Flint, 
M.D. 

"It is with great pleasure, indeed, that we an- 
nounce the publication in this country, by the Ap- 
pletons, of this most superb work. Of all the 
medical works which have been, and which will be, 
published this year, the most conspicuous one as 
embodying learning and research — the compilation 
into one great volume, as it were, of the whole sci- 
ence and art of medicine^s the ' Dictionary of 
Medicine' of Dr. Quain. Ziemen's 'Practice of 
Medicine ' and Reynolds's ' System of IMedicine ' 
are distinguished works, forming compilations, in 
the single department of practice, of the labors of 
many very eminent physicians, each one in his con- 
tributions presenting the results of his own observa- 
tions and experiences, as well as those of the inves- 
tigations of others. But in the dictionaiy of Dr. 
Quain there are embraced not merely the principles 
and practice of medicine in the contributions by the 
various writers of eminence, but general pathology, 
general therapeutics, hygiene, diseases of women 
and children, etc." — Cincinnati Medical Neivs. 

" Criticism in detail we have not attempted, and 
this is in the main because there is not much room 



for it. Those who are most competent to pass an 
opinion will, we believe, admit that Dr. Quain has 
carried out a most arduous enterprise with great 
success. His ' Dictionary of Medicine ' embodies 
an enormous amount of information in a most ac- 
cessible form, and it deserves to take its place in the 
library of every medical man as a ready guide and 
safe counselor. Others, too, will find within its 
pages so much information of various kinds that it 
can not fail to establish itself as a standard work of 
reference." — St. James's Budget. 

" Therefore we believe that as a whole the work 
will admirably fulfill its purpose of being a standard 
book of reference until, like other dictionaries of 
progressive science, it will require to be remodeled 
or supplemented to keep pace with advancing 
knowledge." — The Lancet {Lo?tdo?i). 

"I think ' Quain's Dictionary of Medicine 'an 
excellent work, and of great practical use for eveiy- 
day reference by the physician." — Alexander J. C. 
Skene, M. D., Professor of the Medical and Surgi- 
cal Diseases of Women, Long Isla?id College Hos- 
pital, Brooklyn, N. Y. 

" I regard ' Quain's Dictionary of Medicine' the 
most important, because most useful, publication of 
its kind issued from the medical press for many a 
year. In fact, I know of no similar work that can 
fitly be compared with it. The extraordinary facili- 
ties Dr. Quain possesses, in the choice of distin- 
guished collaborators, have been applied to the con- 
struction of a volume whose contents are so clear 
and compact, yet so full, that the hungriest seeker 
after the latest results of strictly medical research 
can be satisfied at one sitting." — Alexander 
Hutchins, M. D. 

" In this important v.-ork the editor has endeav- 
ored to combine two features or purposes : in the 
first place, to offer a dictionary of the technical 
words used in medicine and the collateral sciences, 
and also to present a treatise on systematic medi- 
cine, in which the separate articles on diseases 
should be short monographs by eminent specialists 
in the several branches of medical and surgical sci- 
ence. Especially for the latter purpose, he secured 
the aid of such well-known gentlemen as Charles 
Murchison, John Rose Cormack, Tilbury Fox, 
Thomas Harden, William Aitken, Cliarlton Bas- 
tian, F>rown-Sequard, Sir William Jenner, Eras- 
mus Wilson, and a host of others. By their aid he 
may fairly be said to liave attained his object of 
' bringing together the latest and most complete in- 
formation, in a form which would allow of ready 
and easy reference.' " — Med. and Surg. Reporter. 



^S D- APPLETON &- CO:S MEDICAL WORKS. 

A PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. Third American from the eighth German edition. Revised 
and enlarged. Illustrated by Six Lithographic Plates. By Alfred 
VoGEL, M. D., Professor of Clinical Medicine in the University of Dorpat, 
Russia. Translated and edited by H. Raphael, M. D., late House Sur- 
geon to Bellevue Hospital ; Physician to the Eastern Dispensary for the 
Diseases of Children, etc., etc. 

I vol., 8vo, 6ii pp. Cloth, $4.50 ; sheep, $5.50. 

The work is well up to the present state of pathological knowledge ; complete without un- 
necessary prolixity ; its symptomatology accurate, evidently the result of careful observation of a 
competent and experienced clinical practitioner. The diagnosis and differential relations of dis- 
eases to each other are accurately described, and the therapeutics judicious and discriminating. All 
polypharmacy is discarded, and only the remedies which appeared useful to the author commended. 

It contains much that must gain for it the merited praise of all impartial judges, and prove it 
to be an invaluable text-book for the student and practitioner, and a safe and useful guide in the 
difficult but all-important department of Psediatrica. 

THE NEW YORK MEDICAL JOURNAL: A Weekly 

Review of Medicine. Edited by Frank P. Foster, M. D. 

The New York Medical Journal, now in the twenty-first year of its publication, is pub- 
lished every Saturday, each number containing twenty-eight large, double-columned pages of 
reading matter. By reason of the condensed form in which the matter is arranged, it contains 
more reading matter than any other journal of its class in the United States. It is also more 
freely illustrated, and its illustrations are generally better executed, than is the case with other 
weekly journals. 

The special departments of the Journal are as follows : 

LECTURES AND ADDRESSES.— The effort is made to present didactic and clinical 
lectures, each in due proportion, and to give under this head only such lectures as are of interest 
to the great body of the profession. 

ORIGINAL COMMUNICATIONS.— These articles cover the whole range of the medical 
sciences, and include only those that are actually contributed by authors, and those that have 
been read before societies with which the Journal has a special arrangement (including the 
New York Surgical Society, the New York Obstetrical Society, the New York Clinical Society, 
and the Medical Society of the County of Kings). 

CLINICAL REPORTS. — These include reports of interesting cases in hospital practice. 

BOOK NOTICES. — In this department books are noticed strictly in accordance with their 
merits. 

CORRESPONDENCE. — Under this head we include only letters from the regular corre- 
spondents of the Journal, chance communications being given under a separate heading. 

LEADING ARTICLES. — Under this head we class the longer and more formal editorial 
articles. They consist either of resiimh of scientific contributions, or of comments on matters of 
interest to the profession as a class, its welfare and its dignity. 

MINOR PARAGRAPHS. NEWS ITEMS. 

OBITUARY NOTES refer for the most part to well-known members of the profession, both 
in this country and abroad. 

LETTERS TO THE EDITOR embrace short communications from others than our regu- 
lar correspondents. 

PROCEEDINGS OF SOCIETIES.— The Journal gives the proceedings of all the lead- 
ing societies, national, State, and local, in a condensed form, but witli a degree of fullness com- 
mensurate with their interest to the profession. 

REPORTS ON THE PROGRESS OF MEDICINE include abstracts of the better part 
of current literature, prepared by a staff of gentlemen specially employed for the purpose. 
These reports cover the whole range of medicine. 

MISCELLANY. — Under this head will be found abstracts which it is thought desirable to 
give in advance of the regular time for their appearance in the formal reports, especially Thera- 
peutical Notes, which, published in nearly every number, furnish the reader with the therapeuti- 
cal novelties of the day. 

The volumes begin with January and July of each year. Subscriptions can be arranged to 
begin with the volume. 

Terms, Payable in Advance : One Year, $5.00 ; Six Months, $2.50 ; Single Copy, 12 
cents. (No subscriptions received for less than six months.) Binding Cases, Cloth, 50 cents. 

THE POPULAR SCIENCE MONTHLY and THE NEW YORK MEDICAL JOUR- 
N.\L to the same address, $9.00 per annum (full price, $10.00). 



D. APPLETON &- CO:S MEDICAL WORKS. -,q 

ATLAS OF FEMALE PELVIC ANATOMY. By D. 

Berry Hart, M. D., F. R. C. P. E., Lecturer on Midwifery and Diseases 
of Women, School of Medicine, Edinburgh, etc. With Preface by Alex- 
ander J. C. Skene, M. D., Professor of the Medical and Surgical Diseases 
of Women, Long Island College Hospital, Brooklyn, etc. 

Large 4to, 37 Plates with 150 Figures, and 8g pages Descriptive Text. Cloth, $15.00. Sold 

only by subscription. 

"Within recent years much has been done to "As a new work by a well-known author, there 

weed the topographical anatomy of the pelvis of is a natural prejudice in its favor, but this becomes 

numerous errors which have encumbered it. Prom- the more deeply rooted as we constantly get new 

inent among those who have furthered this work is views of old fields, new landmarks for better out- 

the author of the 'Atlas' now before us, and into looks, new light upon heretofore obscure points, 

this, his latest labor, he has entered with all his ac- In a word, we can, after the most critical study of 

customed vigor. . . . The ' Atlas deserves, and its contents, say with the distinguished editor, Pro- 

wiU surely have, a wide circulation ; and we are fessor Skene, that ' it is far in advance of any work 

confident that no one will rise from its careful pe- of its kind yet produced.' As such it becomes a 

nisal without having obtained clearer, more accu- necessity for the progressive gynaecologist, for the 

rate, and more intelligent views in regard to the operating surgeon, and for the leading general 

much-vexed questions of female anatomy, or with- practitioner. We congratulate the publishers on 

out having formed a very high opinion of the au- the reproduction of this grand work, and bespeak 

thor's industry, earnestness, and ability." — Edin- for it a becoming appreciation by the profession of 

burgh Medical Journal. this country." — Medical Record. 

ELEMENTS OF PRACTICAL MEDICINE. By Alfred 

H. Carter, M. D., Member of the Royal College of Physicians, London ; 
Physician to the Queen's Hospital, Birmingham, etc. 

Third edition, revised and enlarged, i vol., i2mo, 427 pages. Cloth, $3.00. 

"Although this work does not profess to be a wisely, perhaps, since we know so little about it ; 

complete treatise on the practice of medicine, it is and of that other almost unknown quantity in 

too full to be called a compend ; it is rather an in- medicine, scrofula, the author has with equal pru- 

troduction to the more exhaustive study embodied dence abstained from saying much. He admits 

in the larger text-books. An idea of the degree to such a condition as scrofulosis, but thinks it has no 

which condensation has been carried in it can be necessary connection with tuberculosis. He is a 

gathered from the statement that but twenty-one believer in the germ-theory of disease, and speaks 

pages are occupied with the diseases of the circula- of Koch's investigations and discoveries as very im- 

tory system. If the reader gets the impression that portant, to him almost conclusive, 
the physical signs are given somewhat too meager- "Notwithstanding the condensed make-up of 

ly, it is to be said that, by way of compensation, the book, it is quite comprehensive, including even 

the symptomatology in general is considered with cutaneous and venereal diseases. It contains much 

admirable perspicuity and good judgment. valuable information, and we may add that it is 

" Leucocythffimia is dismissed with one page — very readable." — New York Medical Journal. 

THE MINERAL SPRINGS OF THE UNITED STATES 

AND CANADA, with Analysis and Notes on the Prominent Spas of 

Europe and a List of Sea-side Resorts, An enlarged and revised edition, 

By George E. Walton, M. D., Lecturer on Materia Medica in the Miami 

Medical College, Cincinnati. 

Second edition, revised and enlarged. I vol., i2mo, 414 pp. With Maps. $2. 

The author has given the analysis of all the springs in this country and those of the principal 
European spas, reduced to a uniform standard of one wine-pint, so that they may readily be com- 
pared. He has arranged tlie springs of America and Europe in seven distinct classes, and de- 
scribed the diseases to which mineral waters are adapted, with references to the class of waters 
applicable to the treatment ; and the peculiar characteristics of each spring as near as known are 
given — also the location, mode of access, and post-office address of every spring are mentioned. 
In addition, he has described the various kinds of baths and the appropriate use of them in the 
treatment of disease. 

" Precise and comprehensive, presenting not only use as intelligently and beneficially as they can other 
reliable.analysis of the waters, but their therapeutic valuable alterative agents." — Sanitarian. 
value, so that physicians can hereafter advise their 



40 



D. APPLETON &-> CO:S MEDICAL WORKS. 



DISEASES OF MEMORY : An Essay in the Positive Psy- 
chology. By Th. Ribot, Author of " Heredity," etc. Translated from the 
French by William Huntington Smith. 

i2mo. Cloth, $1.50. 



"Not merely to scientific, but to all thinking 
men, this volume will prove intensely interesting." 
— New York Observer. 

" M. Ribot has bestowed the most painstaking 
attention upon his theme, and numerous examples 
of the conditions considered greatly increase the 
value and interest of the volume." — Pliiladelphia 
North American. 

" ' Memory,' says M. Ribot, ' is a general func- 
tion of the nervous system. It is based upon the 
faculty possessed by the nervous elements of con- 
serving a received modification, and of forming as- 
sociations.' And again : ' Memory is a biological 
fact. A rich and extensive memory is not a collec- 
tion of impressions, but an accumulation of dynam- 



ical associations, very stable and very responsive to 
proper stimuli. . . . The brain is like a laboratory 
full of movement where thousands of operations are 
going on all at once. Unconscious cerebration, not 
being subject to restrictions of time, operating, so to 
speak, only in space, may act in several directions 
at the same moment. Consciousness is the narrow 
gate through which a very small part of all this 
work is able to reach us.' M. Ribol thus reduces 
diseases of memory to law, and his treatise is of ex- 
traordinary interest." — Philadelphia Press. 

" It is not too much to say that in no single work 
have so many curious cases been brought together 
and interpreted in a scientific manner." — Boston 
Evening Traveller. 



A TREATISE ON INSANITY, in its Medical Relations. 
By William A. Hammond, M. D., Surgeon-General U. S. Army (retired 
list) ; Professor of Diseases of the Mind and Nervous System, in the New 
York Post-Graduate Medical School ; President of the American Neuro- 
logical Association, etc. 

I vol., 8vo, 767 pp. Cloth, $5; sheep, $6. 

In this work the author has not only considered the subject of Insanity, but has prefixed that 
division of his work with a general view of the mind and the several categories of mental faculties, 
and a full account of the various causes that exercise an influence over mental derangement, such 
as habit, age, sex, hereditary tendency, constitution, temperament, instinct, sleep, dreams, and 
many other factors. 

Insanity, it is believed, is in this volume brought before the reader in an original manner, and 
with a degree of thoroughness which can not but lead to important results in the study of psycho- 
logical medicine. Those forms which have only been incidentally alluded to or entirely disregard- 
ed in the text-books hitherto pul^lished are here shown to be of the greatest interest to the general 
practitioner and student of mental science, both from a normal and abnormal stand-point. To a 
great extent the work relates to those species of mental derangement which are not seen within 
asylum walls, and which, therefore, are of special importance to the non-asflum physician. 
Moreover, it points out the symptoms of Insanity in its first stages, during which there is most 
hope of successful medical treatment, and before the idea of an asylum has occurred to the patient's 
friends. 



" We believe we may fairly say that the volume 
is a sound and practical treatise on the subject with 
which it deals ; contains a great deal of information 
carefully selected and put together in a pleasant and 
readable form ; and, emanating, as it does, from an 
author whose previous works have met with a most 
favorable reception, will, we have little doubt, obtain 
a wide circulation." — The Dublin Journal of Medi- 
cal Science. 

"... The times are ripe for a new work on in- 
sanity, and Dr. Hammond's great work will serve 
hereafter to mark an era in the history of American 
psychiatry. It should be in the hands of every 
physician who wishes to have an understanding of 
the present status of this advancing science. Who 
begins to read it will need no urging to continue ; 
he will bs carried along irresistibly. We unhesitat- 
ingly pronounce it one of the best works on insan- 
ity which has yet appeared in the English language." 
. — American 'Journal of the Medical Sciences. 

" Dr. Hammond is a bold and strong \%Titer, has 
given much study to his subject, and expresses him- 
self so as to be understood by the reader, even if the 
latter does not coincide with him. We like the book 
very much, and consider it a valuable addition to the 
literature of insanity. We have no hesitancy in 



commending the book to the medical profession, as 
it is to them it is specially addressed." — Therapeutic 
Gazette. 

" Dr. Hammond has added another great work 
to the long list of valuable publications which have 
placed him among the foremost neurologists and 
alienists of America ; and we predict for this volume 
the happy fortune of its predecessors — a rapid jour- 
ney through paying editions. We are sorry that our 
limits will not permit of an analysis of this work, 
the best text-book on insanity that has yet appeared." 
— The Polyclinic. 

" We are ready to welcome the present volume 
as the most lucid, comprehensive, and practical ex- 
position on insanity that has been issued in this 
country by an American alienist, and furthermore, 
it is the most instructive and assimilable that can be 
placed at present in the hands of the student unini- 
tiated in psychiatrj-. The instruction contained 
within its pages is a food thoroughly prepared for 
mental digestion : rich in the condiments that stimu- 
late the appetite for learning, and substantial in the 
more solid elements that enlarge and strengthen the 
intellect." — New Orleans Medical and Surgical 
Journal. 



D. APPLETON &- CO.'S MEDICAL WORKS. 4 1 

THE POPULAR SCIENCE MONTHLY. Conducted by 
E. L. and W. J. Youmans. 

The volumes begin in May and November of each year. Subscriptions may begin at any time. 
Terms, $5 per annum ; single number, 50 cents. 

"The Popular Science Monthly" and "New York Medical Journal" to one address, $9 per 
annum (full price, $10). 

" The Popular Science Monthly " was established a dozen years ago to bring before the general 
public the results of scientific thought on many large and important questions which could find no 
expression in the current periodicals. Scientific inquiry was penetrating many new fields, extend- 
ing important knowledge, and profoundly affecting opinion upon numberless questions of specula- 
tive and practical interest. It was the policy of this magazine at the outset, and has been con- 
stantly adhered to since, to obtain the ablest statements from the most distinguished scientific men 
of all countries in their bearing upon the higher problems of investigation. Leaving the dry and 
technical details of science, which are of chief concern to specialists, to the journals devoted to 
them, " The Popular Science Monthly " has dealt with those more general and practical subjects 
which are of the greatest interest and importance to the people at large. 

That which was at first a dubious experiment has now become an assured and permanent suc- 
cess. Our " Monthly " is the acknowledged organ of progressive scientific ideas in this country. 
Received with favor at the outset, it has gone on increasing in circulation and in influence, until its 
power is felt and acknowledged in the highest departments of intellectual activity, and its leader- 
ship is recognized in the great work of liberalizing and educating the popular mind. 

Making neither sensational appeals nor flaring announcements, we may now refer to its course 
in the past as a sufilcient guarantee that it will continue to discuss in the same earnest and fearless, 
but always respectful manner, the various important questions falling within its scope that are en- 
titled to the intelligent consideration of thinking people. The twenty-three volumes now published 
constitute the best library of advanced scientific knowledge to be found in any country, and each 
new volume is certain to prove of increasing interest and value. 

Science is the great agency of improvement in this age, private and public, individual, social, 
professional, and industrial. In its irresistible progress it touches everywhere, and affects every- 
body. It gives law to the material interests of the community, and modifies its ideas, opinions, 
and beliefs, so that all have an interest in being informed of its advancement. Those, therefore, 
who desire to know what is going on in the world of thought in these stirring times, when new 
knowledge is rapidly extending, and old errors are giving way, will find that they can keep informed 
only by subscribing for " The Popular Science Monthly." 

" This is one of the very best periodicals of its to persons of literary tastes who have neither time 
kind published in the world. Its corps of contribu- nor opportunity to prosecute special scientific re- 
tors comprise many of the ablest minds known to searches, but who, nevertheless, wish to have a cor- 
science and literature." — A^jierican Medical Jour- rect understanding- of what is being done by others 
nal (St. Louis). in the various departments of science." — Louisiana 

,, -, . .-r- . , . ,• -xi .1 • 'journal of Educatioji. 

" No scientific student can dispense with this •' 

monthly, and it is difficult to understand how any " A journal of eminent value to the cause of 

one making literaiy pretensions fails to become a popular education in this country." — Nevo York 

regular reader of this journal. ' The Popular Sci- Tributie. 

ence Monthly ' meets a want of the medical profes- ,, „ ,. • • , ^ ,., , u i_ ^i.- 1 

sion not otherwise met. It keeps full pace with the , , ^veiy physician s table should bear this valu- 

progress of the times in all the departments of sci- ^^le monthly, which we believe to be one of the 

entific pursuit."- Virginia Medical Monthly. "^ost >nterest.ng and instructive of he periodicals 

*^ '^ now published, and one which is destined to play a 

" Outside of medical journals, there is no peri- large part in the mental development of the laity of 

odical published in America as well worthy of being this country." — Canadian yournal of Medical Sci- 

placed upon the physician's library-table and regu- ence. 

larly read by him as " The Popular Science Month- ,. _, . . . .... • ,. • ,, /• 

ly. ' "St. Louis Clinical Record. ., ^his magazine is worth its weigh in gold, for 

■' its service in educating the people. — Americaii 

" ' The Popular Science Monthly ' is invaluable Journal of Education {St. Louis). 

DISEASES OF THE OVARIES: Their Diagnosis and 

Treatment. By T. Spencer Wells, Fellow and Member of Council of 

the Royal College of Surgeons of England, etc., etc. 

I vol., 8vo, 478 pp. Illustrated. Cloth, $4.50. 

In 1865 the author issued a volume containing reports of one hundred and fourteen cases of 
Ovariotomy, which was little more than a simple record of facts. The book was soon out of print, 
and, though repeatedly asked for a new edition, the author was unable to do more than prejiare 
papers for the Royal Medical and Chirurgical Society, as series after series of a hundred cases ac- 
cumulated. On the com]-)lelion of five hundred cases, he embodied the results in tlie present vol- 
ume, an entirely new work, for the student and practitioner, and trusts it may prove acceptable to 
them and useful to suffering women. 



42 



D. APPLETON &- CO:S MEDICAL WORKS. 



LECTURES ON THE PRINCIPLES OF SURGERY. 

Delivered at the Bellevue Hospital Medical College. By the late W. H. 
Van Buren, M. D., LL. D. Edited by Dr. Lewis A. Stimson. 

I vol., 8vo, 588 pages. Cloth, $4.00 ; sheep, $5.00. 



" The name of the author is enough. The book 
will sell. The lectures are good." — Denver Medi- 
cal Times. 

" If we are to judge of the interesting style by 
the mere reading of these lectures, how greatly they 
must have been appreciated by those who heard 
them by the teacher ! There is nothing dry or prosy 
in them. The illustrations of principles are drawn 
from the clinical material of the teacher, and are 
always fresh and a propos. Past and present theo- 
ries are compared in such a way as to give the stu- 
dent an interest in the work of older pathologists, 
and to point out progress made, without wearying 



him with a dry narration at a time when he is not 
able to comprehend the underlying philosophy. 

" Dr. Van Buren's popularity as a teacher can 
be easily understood from a study of this volume. 
His manner is vivacious, his matter select, and his 
fullness of knowledge easily discernible. He writes 
like one in authority, full of enthusiasm, and pos- 
sessed of the skill of imparting to students just that 
sort of knowledge best suited to their future intel- 
lectual growth. 

"The work is handsomely printed, with full- 
faced, clear type and leaded lines, and is in every 
way a credit to the publishers." — North Carolina 
Medical Journal. 



OSTEOTOMY AND OSTEOCLASIS, for the Correction of 

Deformities of the Lower Limbs. By Charles T. Poore, M. D., Surgeon 
to St. Mary's Free Hospital for Children, New York. 

I vol., Svo, 202 pages, with 50 Illustrations. Cloth, $2.50, 





" This handsome and carefully-prepared mono- 
graph treats of osteotomy as applied to the repair 
of genu valgum, genu varum, anchylosis of the 
knee-joint, deformities of the hip-joint, and for 
curves of the tibia. The author has enjoyed large 
opportunities to study these special malformations 
in the hospitals to which he is attached, and de- 
scribes the operations from an ample observation. 
Quite a number of well-engraved illustrations add 
to the value of the volume, and an exhaustive bib- 
liography appended enables the reader to pursue 
any topic in which he may be interested into the 
productions of other writers." — Medical and Sur- 
gical Reporter. 

" Dr. Poore, who has already become so well 
known by journal articles on bone surgery, has con- 



densed his experience in the work before us. He 
has succeeded in doing this in a very satisfactory 
way. We can not too strongly commend the clear 
and succinct manner in which the author weighs 
the indications for treatment in particular cases. 
In so doing he shows a knowledge of his subject 
which is as extensive as it is profound, and no one 
at all interested in orthopedy can read his conclu- 
sions without profit. His own cases, which are 
carefully reported, are valuable additions to the lit- 
erature of the subject. These, together with oth- 
ers, which are only summarized, contain so much 
practical information and sound surgery that they 
give a special value to the work, altogether inde- 
I>endent of its other excellences. It is a good book 
in every way, and we congratulate the author ac- 
cordingly." — Medical Record. 



D. APPLETON &- CO:S MEDICAL WORKS. 



43 



A TREATISE ON BRAIN-EXHAUSTION, with some 

Preliminary Considerations on Cerebral Dynamics. By J. Leonard Corn- 
ing, M. D., formerly Resident Assistant Physician to the Hudson River 
State Hospital for the Insane ; Member of the Medical Society of the 
County of New York, of the Physicians' Mutual Aid Association, of the 
New York Neurological Society, of the New York Medico-Legal Society, 
of the Society of Medical Jurisprudence ; Physician to the New York Neu- 
rological Infirmary, etc. ; Member of the New York Academy of Medicine. 

Crown 8vo. Cloth, $2.00. 



" Dr. Coming's neat little volume has the merit 
of being highly suggestive, and, besides, is better 
adapted to popular reading than any other profes- 
sional work on the subject that we know of." — Pa- 
cific Medical and Surgical Journal. 

"This is a capital little work on the subject 
upon which it treats, and the author has presented, 
from as real a scientific stand-point as possible, a 
group of symptoms, the importance of which is 
sufficiently evident. To fully comprehend the ideas 
as presented by the author, the whole book should 
be read ; and, as it consists of only 234 pages, the 
task would not be a severe or tedious one, and the 
information or knowledge obtained would be much 
more than equivalent for the time spent and cost 
of book included. Literary men and women would 
do well to procure it." — Therapeutic Gazette. 



" This book belongs to a class that is more and 
more demanded by the cultured intelligence of the 
period in which we live. Dr. Corning may be 
ranked with Hammond, Beard, Mitchell, and 
Crothers, of this country, and with Winslow, An- 
stie, Thompson, and more recent authors of Great 
Britain, in discussing the problems of mental dis- 
turbance, in a style that makes it not only profit- 
able but attractive reading for the student of psy- 
chology. The author has divided the work into 
short chapters, under general headings, which are 
again subdivided into topics, that are paragraphed 
in a concise and definite form, which at once strikes 
the careful reader as characteristic of a method that 
is terse, concise, and readily apprehended. There 
are twenty-eight of these pithy chapters, which no 
student of mental diseases can fail to read without 
loss." — American Psychological jfournal. 



PRACTICAL MANUAL OF DISEASES OF WOMEN 

AND UTERINE THERAPEUTICS. For Students and Practitioners. 
By H. Macnaughton Jones, M. D., F. R. C. S. I. and E., Examiner in 
Obstetrics, Royal University of Ireland ; Fellow of the Academy of Medi- 
cine in Ireland ; and of the Obstetrical Society of London, etc. 

I vol., i2mo. 410 pages. 1S8 Illustrations. Clolh, $3,00. 



"As a concise, well-written, useful manual, we 
consider this one of the best we have ever seen. 
The author, in the preface, tells us that ' this book 
is simply intended as a practitioner's and student's 
manual. I have endeavored to make it as practical 
in its teachings as possible.' The style is pleasant 
to peruse. The author expresses his ideas in a clear 
manner, and it is well up with the approved meth- 
ods and treatment of the day. It is well illustrated, 
and due credit is given to American gynecologists 
for work done. It is a good book, well printed in 
good, large type, and well bound." — New England 
Medical Monthly. 

" It is seldom that we see a book so completely 
fill its avowed mission as does the one before us. 
It is practical from beginning to end, and can not 
fail to be appreciated by the readers for whom it is 
intended. The author's style is terse and perspicu- 
ous, and he has the enviable faculty of giving the 
learner a clear insight of his methods and reasons 
for treatment. Prepared for the practitioner, this 
little work deals only with his every-day wants in 
ordinary family practice. Every one is compelled 
to treat uterine disease who does any general busi- 
ness whatever, and should become acquainted with 
the minor operations thereto pertaining. The book 



before us covers this ground completely, and we 
have nothing to offer in the way of criticism." — 
Medical Record. 

" The manual before us is not the work of a spe- 
cialist—using this term in a narrow sense — but of 
an author already favorably known to the students 
of current medical literature by various and com- 
prehensive works upon other branches of his profes- 
sion. Nor is it, on the other hand, the work of an 
amateur or merely ingenious collaborateur, for Dr. 
Macnaughton Jones's gynecological experience in 
connection with the Cork Hospital for Women and 
the Cork Maternity was such as fairly entitles him 
to speak authoritatively upon the subjects with 
which it deals. But, after so many works by avowed 
specialists, we are glad to welcome one upon Gynae- 
cology by an author whose opportunities and energy 
have enabled him to master the details of so many 
branches of medicine. We are glad also to be able 
to state that his work compares very favorably with 
others of the same kind, and that it does admirably 
fulfill the purposes with which it was written—' as 
a safe guide in practice to the practitioner, and an 
assistance in the study of this branch of his profes- 
sion to the student.'" — Dublin J our }tal 0/ Medical 
Science. 



44 



D. APPLETON &- CO:S MEDICAL WORKS. 



A HAND-BOOK OF THE DISEASES OF THE EYE, 

AND THEIR TREATMENT. By Henry R. Swanzy, A. M., M. B., 
F. R. C. S. I., Surgeon to the National Eye and Ear Infirmary ; Ophthalmic 
Surgeon to the Adelaide Hospital, Dublin. 

Crown 8vo, 437 pages. With 122 Illustrations, and Holmgren's Tests for Color-BIindness. 

Cloth, $3.00. 



" Though, amid the numerous recent text-books 
on eye-diseases, there would appear to be little 
room or necessity for another, we must admit that 
this one justifies its presence, by its admirable type, 
illustrations, and dress, by its clear wording, and, 
above all, by the vast amount of varied matter 
which it embraces within the relatively small com- 
pass of some four hundred pages. The author has 
omitted — and, in our opinion, with perfect wis- 
dom — the usual collection of indifferent, second- 
hand ophthalmoscopic plates. So, also, he has not 
included test-types, though he has appended, for 
explanatory purposes, the fan which is often used 
in astigmatism. Admirable samples of the colored 
wools, used in Holmgren's tests, are sewn into the 
cover, and, by aid of these, it will be perfectly within 



the power of any one, wherever residing, to make a 
proper collection of colored wools and tests for the 
qualitative estimation of congenital color-defects. 
We have criticised the book at length, and drawn at- 
tention freely to points on which the author's opin- 
ion is at variance with the commonly received teach- 
ing. This we have done because there is much 
individuality in the work, which bears every mark 
of having been well thought out and independently 
written. In these respects it presents a marked su- 
periority over the ordinary run of medical hand- 
books ; and we have no hesitation in recommending 
it to students and young practitioners as one of the 
very best, if not actually the best, work to procure 
on the subject of ophthalmology." — British Medi- 
cal Journal. 



DISEASES OF THE HEART AND THORACIC AOR- 
TA. By Byrom Bramwell, M. D., F. R. C. P. E., Lecturer on the Prin- 
ciples and Practice of Medicine and on Medical Diagnosis in the Extra- 
Academical School of Medicine, Edinburgh ; Pathologist to the Royal 
Infirmary, Edinburgh, etc. 

Illustrated with 226 Wood Engravings and 68 Lithograph Plates, showing 91 Figures — in all, 
317 Illustrations. 1 vol., Svo, 783 pages. Cloth, $8.00 ; sheep, $9.00. 



" A careful perusal of this work will well repay 
the student and refresh the memory of the busy 
practitioner. It is the outcome of sound knowledge 
and solid work, and thus devoid of all ' padding,' 
which forms the bulk of many monographs on this 
and other subjects. The material is treated with 
due regard to its proportionate importance, and the 
author has well and wisely carried out his apparent 
intention of rather furnishing a groundwork of 
knowledge on which the reader must build for him- 
self by personal observation, than of making excur- 
sions into the region of dogma and of fancy by 
which his book might have secured a perhaps more 
rapid but certainly a more evanescent success than 
that which it will now undoubtedly and deservedly 
attain." — Medical Times and Gazette. 

" In this elegant and profusely illustrated vol- 
ume Dr. Bramwell has entered a field which has 
hitherto been so worthily occupied by British au- 
thors — Hope, Hayden, Walshe, and others ; and 



we can not but admire the industry and care which 
he has bestowed upon the work. As it stands, it 
may fairly be taken as representing the stand-point 
at which we have arrived in cardiac physiology and 
pathology ; for the book opens with an extended 
account of physiological facts, and especially the 
advances made of late years in the neuro-muscular 
mechanism of the heart and blood-vessels. Al- 
though in this respect physiological research has 
outstripped clinical and pathological observation, 
Dr. Bramwell has, we think, done wisely in so in- 
troducing his treatise, and has thereby greatly add- 
ed to its value. A chapter upon thoracic aneurism 
terminates a work which, from the scientific man- 
ner in which the subject is treated, from the care 
and discrimination exhibited, and the copious elab- 
orate illustrations with which it is adorned, is one 
which will advance the author's reputation as a 
most industrious and painstaking clinical observer." 
— Lancet. 



PHYSIOLOGY, 

Sanitary Inspector of 



THE ESSENTIALS OF ANATOMY, 

AND HYGIENE. By Roger S. Tracy, M. D., 

the Ne\v York City Health Department. 

l2mo. Cloth, $1.25. 

This work has been prepared in response to the demand for a thoroughly scientific and yet 
practical text-book for schools and academies, which shall afford an accurate knowledge of the 
essential facts of Anatomy and Physiology, as furnishing a scientific basis for the study of 
Hygiene and the Laws of Health. It also treats, in a rational manner, of the physiological effects 
of alcohol and other narcotics, fulfilling all the requirements of recent legislative enactments upon 
this subject. • 



D. APPLETON &- CO:S MEDICAL WORKS. ac 

THE RELATION OF ANIMAL DISEASES TO THE 

PUBLIC HEALTH, and their Prevention : With a Brief Historical 
Sketch of the Development of Veterinary Medicine, from the Earliest Ages 
to the Present Time ; and a Critical Historical Sketch of the Leading 
Schools of .the World, showing the Reasons which led to their Foundation, 
and with the Endeavor to draw from their Experiences Teachings of Value 
toward the Establishment of a General Veterinary Police-hygienic System 
and Veterinary Schools in this Country. By Frank S. Billings, Veteri- 
nary Surgeon, Graduate of the Royal Veterinary Institute, Berlin ; Mem- 
ber of the Royal Veterinary Association of the Province of Brandenburg, 
Prussia ; Honorary Member of the Veterinary Society of Montreal, Can- 
ada, etc., etc. 

I vol., 8vo. Cloth, $4.00. 

" This is the great health-book of Dr. Frank S. least should be in the libraries of every national, 
Billings, and it is not too much to promise that a State, city, town, and county Board of Health. It 
study and observance of its teachings, that are the certainly should be studied by every teacher and 
results of actual experiments, will vi'ork a revolution scientific practitioner of veterinary medicine, and 
in the sanitary condition of the United States. . . . will be of great service to every great stock and cat- 
It is a work for all stock-breeders and for all fami- tie holder and dealer. ... It is evidently written 
lies." — Louisville Courier-Jouriial. by a man of great ability and high culture, well 

u T-u- • 41, t-n„ ^r , „ 1 ■,,.*„• „ *^ n,„ versed both in the literature and science as well as 

"This is the title of a work lUSt given to the ., ..• 1 u ■ r i_- u- i. c- i, 

,,,.., u- . / •.. r- .^ i the practical beanne;s of his subiect. Such a man 

world, and in its pages subjects of vital interest are , ^ . j • f- ui ■ uJ ^ u 

treated of in a lucid and oersoicuous manner ^^^ ^ ^reat and inalienable right to have opinions 

treated ot in a iucid and perspicuous manner. . . ^ ^. ^^^ j ^ j ^ ^ hesitate 

These well-established statements should arouse the . '., tx- v^ j u i- tu ^ 

, ,. , .. , n VI th t hr dc; of he 1th express them. ... We hope and believe that 

should he mfeful and'^fficient in The exercise of *^^ volume will be received by all, except perhaps 

should be caretut and emcient in tne exercise ot by those especially attacked, with the great welcome 

their duties, as also that, as individuals, every one 4./ ^ ^ "Tu j ur u * ^ c v 

, ,j 1 u , t 1 ^ (■ 1 •„ If u- j: ~ that its author and pubhshers must expect for it. 

should labor to take good care of himself, his fam- ti -n ^ 1 •» ,. j 1 -j r ^u 1 

ilv and his domestic animals "—JVew York Times ^^ ^^^^ ^^^^ "^ ^'^"'^ alongside of the popular trea- 

iiy, and nis domestic animals. i\ew lotu limes, ^j^^^ ^^ Milliard and Robertson, and on all purely 

" This handsome volume does great credit to its scientific matters will lead them. Either of these 
author and pubhshers. It is an excellent book in works, together with Dr. Billings's, will make al- 
most respects, an extraordinary one in many, and most a complete library on veterinary medicine." — 
an objectionable one in very few. It at the very your?ial 0/ Co/npat-ative Medici?ie a?id Surgery, 

PYURIA; OR. PUS IN THE URINE, AND ITS TREAT- 

MENT : Comprising the Diagnosis and Treatment of Acute and Chronic 
Urethritis, Prostatitis, Cystitis, and Pyelitis, with especial reference to their 
Local Treatment. By Dr. Robert Ultzmann, Professor of Genito-Uri- 
nary Diseases in the Vienna Poliklinik. Translated, by permission, by Dr. 
Walter B. Platt, F. R. C S. (Eng.), Baltimore. 

i2mo. Cloth, $1.00. 

" Those of the profession who are familiar with but also for the many practical suggestions regard- 

the works of Professor Ultzmann will welcome this ing treatment to be found in the chapter on Thera- 

translation as constituting a real addition to our lit- peutics. The translator is to be congratulated upon 

erature on genito-urinary diseases. It can not be the excellent manner in which his work has been 

too highly recommended to the attention of the pro- accomplished. The book is neatly and tastefully got 

fession, not only on account of its scientific value, up by the publishers." — Maryland Med. Journal. 

HAND-BOOK OF SANITARY INFORMATION FOR 

HOUSEHOLDERS. Containing Facts and Suggestions about Ventila- 
tion, Drainage, Care of Contagious Diseases, Disinfection, Food, and 
Water. With Appendices on Disinfectants and Plumbers' Materials. By 
Roger S. Tracy, M. D., Sanitary Inspector of the New York City Health 

Department. 

l6mo. Cloth, 50 cents. 



INDEX. 



Anaesthesia, Hospitalism, etc 23 

Anatomy 12, 17, 22, 28, 39, 44 

Barker on Puerperal Disease 3 

On Sea-Sickness 3 

Bartholow's Materia Medica and Therapeutics. . 5 

Practice of Medicine 6 

Antagonism between Medicines, etc 7 

Bastian's Paralysis from Brain Disease 3 

Brain as an Organ of Mind 5 

Bennett's Winter and Spring on the Mediterra- 
nean 7 

Treatment of Pulmonary Consumption. ... 7 

Bile, Jaundice, and Bilious Diseases ig 

Billings. Animal Diseases and the Public Health. 45 
Billroth's Surgical Pathology and Therapeutics. 8 

Bones, Diseases of 26 

Brain and its Functions 36 

Brain as an Organ of the Mind 5 

Brain Exhaustion 43 

Bramwell. Diseases of the Heart 44 

Breath 19 

Buck's Contributions to Reparative Surgery. ... 14 

Carpenter's Mental Physiology 4 

Carter. Elements of Practical Medicine 39 

Chauveau's Anatomy of Domesticated Animals. 12 

Chemical Technology 33 

Chemistry 4, 35 

Chemistry of Common Life 14 

Children's Diseases 30, 38 

Club-Foot 30 

Combe on the Management of Infancy 3 

Cooley's Cyclopsedia of Practical Receipts 12 

Corfield on Health 4 

Corning. Brain Exhaustion 48 

Davis. Conservative Surgery 13 

Electro-Therapeutics, Clinical 22 

Elliot's Obstetric Clinic g 

Emergencies 16 

Evetzky on Ergot 8 

Eye, Diseases of the 44 

Flint's Physiology 10, 11 

Effects of Muscular Exercise g 

Examination of Urine g 

Source of Muscular Power g 

Floating Matter in the Air 27 

Foods 23 

Fournier on Syphilis and Marriage n 

Frey's Histology of Man 13 

Galvano-Therapeutics 25 

Gamgee. Yellow Fever 13 

Genito-Urinary Organs 34 

Gross on Tumors of the Mammary Gland 15 

Gutmann's Watering-Placesand Mineral Springs 30 

Hamilton's Clinical Electro-Therapeutics 22 

Hammond's Diseases of the Xervous System ... 16 

Insanily 40 

Clinical Lectures 17 

Hart. Atlas of Female Pelvic Anatomy 3g 

Harvey's First Lines of Therapeutics ig 

J^ealth. 4, 24, 31, 45 

Health Primers 21 

Heart, Diseases of the 44 

Histology and Histo-Chemistry of Man 13 

Hoffmann and Ultzmann. Analysis of Urine. . 22 

Hospitals '. 25 

Howe on Emergencies 16 

on the Breath ig 

Huxley's Anatomy of Vertebrated Animals 17 

Anatomy of Invertebrated Animals 22 

Infancy 3 

In-Knee, Medical and Surgical Aspects of 36 

Insanity 40 

Johnson's Chemistry of Common Life 14 

Jones. Diseases of Women 43 

Keyes on Tonic Treatment of Syphilis 14 

Kingsley's Oral Deformities 18 

Legg on Bile, Jaundice, and Bilious Diseases. . . ig 
Lettermann's Medical Recollections 24 



Little on In-Knee 36 

Lusk's Midwifery 2© 

Luys. The Brain and its Functions 35 

McSherry on Health 24 

Mammary Gland i c 

Markoe's Diseases of the Bones 26 

Materia Medica and Therapeutics 5, 26 

Maudsley's Body and Mind 24 

Responsibility in Mental Disease 24 

Pathology of the Mind 23 

Physiology of the Mind 25 

Medicine. 6, 7, 27, 36, 3g 

Memory, Diseases of 40 

Mental Physiology . 

Midwifery 20, 34 

Mineral Springs 30, 30 

Ministry of Health 2g 

Modern Life, Diseases of 30 

Neftel's Galvano-Therapeutics 25 

Nervous System 16, 17 

Neumann's Skin-Diseases 



23 

New York Medical Journal 33 

Niemeyer's Practice of Medicine 27 

Nightingale's Notes on Nursing 26 



Obstetrics. 



g, 23 

Oral Deformities 1 j^ 

Osteotomy and Osteoclasis 42 

Oswald's Physical Education 25 

Ovarian Tumors 26 

Ovaries, Diseases of 41 

Paralysis from Brain-Disease 3 

Peaslee on Ovarian Tumors 26 

Pereira's Materia Medica 26 

Physical Education 25 

Physiological Effects of Muscular Exercise g 

Physiology 10, u, 44 

Physiology of Muscles and Nerves 36 

Poore. Osteotomy and Osteoclasis 42 

Popular Science Monthly 41 

Puerperal Diseases 3 

Pulmonary Consumption 7 

Pyuria ; or. Pus in the Urine 45 

Quain's Dictionary of Medicine 36 

Ranney's Anatomy of the Nervous System 28 

Rectum, Diseases of 32 

Reports, Bellevue and Charity Hospital 32 

Ribot's Diseases of Memory 40 

Richardson's Diseases of Modern Life 30 

Ministry' of Health 2g 

Roscoe and Schorlemmer's Chemistry 35 

Rosenthal's Physiology of Muscles and Nerves. . 36 

Sanitary Information 45 

Sayre's Orthopedic Surgery 31 

Club-Foot 30 

Schroeder's Midwiferj- 34 

Simpson's (Sir James Y.) Works 23 

Skin-Diseases 23 

Smith on Foods 33 

on Health 31 

Source of Muscular Power g 

Steiner on Children's Diseases 30 

Surgery 13, 14, 31, 42 

Swanzy. Diseases of the Eye 44 

Syphilis 11, 14 

Tracy. Anatomy and Physiology 44 

Tyndall's Floating Matter 27 

Urine g, 22, 45 

Van Buren and Keyes. Genito-Urinary Organs. 34 

Van Buren. Diseases of the Rectum 32 

Lectures on Surgery 42 

Vogel's Diseases of Children 38 

Wagner's Chemical Technology 33 

Walton's Mineral Springs 3g 

Wells. Diseases of the Ovaries 41 

Winter and Spring on the Mediterranean 7 

Women, Diseases of 33, 43 

W^ylie's Hospitals 35 

Yellow Fever 13 



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GYNAECOLOGICAL TRANSACTIONS, VOL. VIII. 

Being the Proceedings of the Eighth Annual Meeting of the American Gyn- 
£ecological Society, held in Philadelphia, September i8, 19, and 20, 1883. 
8vo vol., 276 pages. Cloth, $5.00. 

A MANUAL OF DERMATOLOGY. By A. R. Robinson, 
M. B., L. R. C. P. and S. (Edin.), Professor of Dermatology at the New 
York Polyclinic ; Professor of Histology and Pathological Anatomy at the 
Woman's Medical College of the New York Infirmary. Revised and cor- 
rected. 

8vo vol., 647 pages. Cloth, $5.00. 

"It includes so much good, original work, and " In general appearance it is similar to Duhring's 

so well illustrates the best practical teachings of the excellent book, more valuable, ho\yever, in that it 

subject by our most advanced men, that I regard it contains much later views, and also on account of 

as commanding at once a place in the very front the excellence of the anatomical description accom- 

rank of all authorities. . . ."^JAMES Nevins panying the microscopical appearances of the dis- 

Hyde, M. D. eases spoken of." — Sf. Louis Med. and Surg. Jour. 

"Dr. Robinson's experience has amply qualified "Altogether h is an excellent work, helpful to 

him for the task which he assumed, and he has given every one who consults its pages for aid in the study 

us a book which commends itself to the considera- of skin-diseases. No physician who studies it will 

tion of the general practitioner."— J/eaTzca/^^^. regret the placing of it in his Xx^ix^xy.''''— Detroit 

Lancet. 

In press, March 1, 1885. 

A TREATISE ON NERVOUS DISEASES: Their Symp- 
toms and Treatment. A Text-Book for Students and Practitioners. By 
S. G. Webber, M. D., Clinical Instructor in Nervous Diseases, Harvard 
Medical School ; Visiting Physician for Diseases of the Nervous System at 
the Boston City Hospital, etc. 

I 8vo volume. 



48 



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the permission of the author, by Henry C. Coe, M. D., M. R. C. S., L. R. 

C. P. (London), Pathologist to the Woman's Hospital of the State of New 

York. 

8vo vol. of 200 pages. 

TRANSACTIONS OF THE NEW YORK STATE 

MEDICAL ASSOCIATION, VOL. I. Being the Proceedings of the First 
Annual Meeting of the New York State Medical Association, held in New 
York, November 18, 19, and 20, 1884. 

GYNECOLOGICAL TRANSACTIONS, VOL. IX. Being 

the Proceedings of the Ninth Annual Meeting of the American Gynaeco- 
logical Society, held in Chicago, September 30, and October i and 2, 1884. 

THE DIAGNOSIS AND TREATMENT OF DISEASES 

OF THE EAR. By Oren D. Pomeroy, M. D., Surgeon to the Manhat- 
tan Eye and Ear Hospital, etc. With One Hundred Illustrations. New 
edition, revised and enlarged. 

8vo vol. Cloth, $3.00. 

A TEXT-BOOK OF OPHTHALMOSCOPY. By Edward 

G. LoRiNG, M. D. Part I. The Normal Eye, Determination of Refraction, 
and Diseases of the Media. Profusely illustrated. 

8vo. 

ELEMENTS OF MODERN MEDICINE, including Prin- 
ciples of Pathology and of Therapeutics, with many Useful Memoranda 
and Valuable Tables of Reference. Accompanied by Pocket Fever Charts. 
Designed for the Use of Students and Practitioners of Medicine. In wallet- 
book form, with pockets on each cover for Memoranda, Temperature 
Charts, etc. By R. French Stone, M. D., Professor of Materia Medica 
and Therapeutics and Clinical Medicine in the Central College of Physi- 
cians and Surgeons, Indianapolis ; Physician to the Indiana Institute for 
the Blind ; Consulting Physician to the Indianapolis City Hospital, etc., 
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